Agenda item

-  General Update (To Follow)

-  Women’s Health Services (Pages 15 - 22)

Jonathan Lofthouse, Site Chief Executive – PRUH and South Sites (“Site Chief Executive”) and Debbie Hutchinson, Site Director of Nursing – PRUH and South Sites (“Site Director of Nursing”) provided an update on the King’s College Hospital NHS Foundation Trust.

General Update

The Site Chief Executive advised that, with regards to elective recovery performance, work was continuing to reduce long waits across all waiting time cohorts in line with the NHS Elective Recover Plan following the backlogs caused by the impact of the COVID-19 pandemic. The London region was the most improved area across the UK – of the five Integrated Care Systems (ICS) in London, South East London was the most improved, and King’s was currently the highest performing of its three Trusts. It was noted that there was still a range of long waiting patients, but King’s was in a good position and continued to progress. Around 13,500 patients were currently waiting for an operation and there were approximately 86,000 patients across the total spectrum, which began from GP referrals. The order book was large, but under control – it grew by around 300 patients per week, which was similar to other Trusts across London. Since February 2022, the PRUH and South Sites had maintained its compliance with the national standard, and less than 1% of patients were waiting more than six weeks for their diagnostic test. The importance of this was highlighted as the quicker the tests were undertaken, the quicker an informed diagnosis could be made, and a treatment plan put in place. It was noted that access for cancer patients had improved – the PRUH performance against the 62-day target was 80% for August, and although below the compliance threshold of 85%, had improved due to the increased speed of diagnostics. For August 2022, 96.2% compliance with the two-week wait standard had been achieved.

In response to a question, the Site Chief Executive said that national standard for diagnostic test included endoscopy, but there were different forms of endoscopy referrals. The target for a routine endoscopy to be completed was six weeks from referral, however there was a multitude of pathways. Endoscopies were one of fourteen diagnostic targets – it was noted that the performance against national standards was collective, however information relating specifically to endoscopy performance could be provided to Members following the meeting. The Portfolio Holder for Adult Care and Health said it was positive to see that the six week diagnostics target was being met and enquired if this impacted on the patient pathway for those needing operations. The Site Chief Executive advised that there were around 13,000 patients across the Trust, and 4,000 patients were allocated to the PRUH and South Sites for operative care. These patients underwent a clinical assessment, and their prioritisation was reviewed against the national levels, 1 (most urgent) to 4, on a rolling weekly basis. At any point in time, due to further referrals, they were around 300 patients behind. For patients requiring urgent operations they aimed to operate within four weeks – this could not always be achieved but they were making substantial inroads. It was suggested that data relating to this could be provided to Members at the next meeting of the Sub-Committee.

With regards to emergency care, the Site Chief Executive advised that attendance at Accident and Emergency (A&E) departments continued to be a challenge across the UK, the Trust and the PRUH. The PRUH’s performance against the four-hour wait target for A&E ranged between 65-70% and this related to full completion of treatment – during this times patients were being triaged and provided with the necessary pain medication. There were seven organisations across London that were particularly challenged with regards to ambulance offloads. The government had three markers in terms of ambulance handover and drop-off – handover in 15 minutes from arrival at a hospital site, 30 minutes and 1 hour. The majority of handovers took place between 30 minutes and 1 hour, and only one or two exceed the 60-minute handover time. In was noted that central government and the regional NHS were aware of these challenges and were supporting the PRUH, and other sites around London. To help address this and an additional £1m had been secured for the PRUH and South Sites and Denmark Hill to aid performance going into the winter period.

A Co-opted Member extended thanks to staff at the PRUH following his recent personal experience at the Emergency Department (ED). The Site Chief Executive thanked the Co-opted Member for his positive comments and advised that these would be fed back to the team. It was noted that around 100,000 patients were seen at the ED each year, and the team strived to offer good care to local residents.

In response to a question, the Site Chief Executive said that from the outset of the COVID-19 pandemic, King’s as an organisation followed the national directions issued by the Department of Health and Social Care and/or Public Health England. These were augmented in real time and were fully registered and audited through the command structure. In terms of current restrictions across the PRUH and South Sites, in clinical based areas face masks were encouraged, and they were required in immunocompromised environments. Following recent intelligence it was likely that sites would encourage the wearing of face masks more widely.

The Site Chief Executive advised that the Trust had received multiple Care Quality Commission (CQC) inspections: maternity services (PRUH); maternity services (Denmark Hill); medicine services (PRUH); and older adults’ services (PRUH). The full feedback from all of these assessments was still awaited. Formal notification had also been received that the organisation’s full assessment would take place on the 15^th and 16^th November 2022. They had however received published feedback in relation to the older adults’ services at Orpington Hospital following an unannounced CQC inspection on 11^th July 2022. The Churchill and Elizabeth Wards had been given a ‘Requires Improvement’ rating in the overall category for care – medical care was rated ‘Inadequate’ for being caring, and ‘Requires Improvement’ for being safe – from a previous assessment of ‘Good’. The areas of concern related to base level staffing; levels of medication and administration; and domestic levels of dignity. Learning had been taken as these two wards had not been flagged as wards of concern – a range of tools were used to monitor the effectiveness of care, and the aspects highlighted by the CQC were behavioural. The Trust’s viewpoint was that all of these concerns had been addressed within three weeks of the CQC findings – they were confident of the robustness of the response and had already invited the CQC to return and reassess these areas. The Site Chief Executive said that Members’ disappointment in these short comings was shared, however it was noted that they had not been found in the PRUH’s older adults’ wards.

In response to questions, the Site Chief Executive advised that a simplified version of the action plan in response to the CQC inspection had been provided. The full action plan was monitored formally by the CQC on a weekly basis – they were up to date on all aspects, and were required to provide reference and evidence. The issues had been addressed within three weeks of the CQC inspection and they were sustaining these high standards. They were confident that the action plan would meet the needs of these areas long term.

A Member noted that a previous CQC inspection of the PRUH’s A&E department had rated the caring element as ‘Inadequate’, and the same had been highlighted during the recent inspection at Orpington Hospital and enquired what cultural changes were being made. The Site Chief Executive said that staff had been equally shocked and disappointed. To provide some context, Members were advised that the visit had taken place on a single day, with single day observations by three inspectors, across three wards. The specific area of concern related to the speed and efficacy of toileting assistance being insufficient, and this had been compromised by the number of staff on the ward. It was noted that the ward had been appropriately staffed, but staff had then been moved to support an alternative care environment on another hospital site. The ward then became short staffed, and this shortage compromised the care being offered to patients – there had been an immediate stop on staff moving to different hospital sites. It was emphasised that this was not a systemic cultural issue, and the shortcoming was caused by the number of staff available to provide care. The Site Director of Nursing echoed the comments regarding the disappointment felt by the outcome of the inspection. Members were advised that it was not just numbers of staffing, there also needed to be the right skill mix and level of support. Earlier in the year it had been recognised that, due to the way in which care groups were managed across a number of sites, the matron support was not as sufficient as they would like. The matron level support had since been considered and reorganised, and just after the CQC inspection a new matron had started and was providing support to the wards at Orpington Hospital. Evidence from the action plan showed that there had been quick and dramatic improvements in the areas identified during the inspection, and this needed to be maintained 24 hours a day, 7 days a week. In response to a further question, the Site Director of Nursing said that the movement of staff was minimised as much as possible, as they knew this was not good for staff or patients. Staffing levels were reviewed two or three times a day and wards were RAG rated – occasionally, if a staff member needed to be moved to avoid a ward becoming RAG rated ‘red’, they would try and do so within the same care group as they would have the same skill set.

The Site Chief Executive informed Members that the Trusts capital developments were continuing. The development of the car park deck, which would provide 197 additional spaces, was on target and Sir Bob Neill MP would be cutting the ribbon during the first week in November. The final plans for the £20m cancer endoscopy unit would be brought to a Plans Sub-Committee in the coming months, and the connecting bridge between the Day Surgery Unit and the main hospital was expected to be completed in late December 2022.

In response to questions, the Site Chief Executive said that car parking was not currently free of charge. There was a pay and display public car park at the hospital, although its capacity had been reduced during the building of the new deck, and provision was also available in the adjoining Sainsbury’s car park. The price of the pay and display parking had been held, and they did not believe it was beyond the market rate. The money went straight into the Trust, and not to a private contractor, and was used to support things such as in-house security. If central government dictated that all parking charges needed to be suspended, they would happily do so. A Member enquired if the staff park and ride scheme would be kept in place. The Site Chief Executive said that the park and ride scheme had been very popular with staff, however it cost around £250k to provide. There would be an overlap period of eight weeks once the new car deck opened, and during this period consideration would be given as to whether the park and ride scheme continued.

Women’s Health Services

The Site Chief Executive informed Members that a full range of maternity service were offered at the core PRUH site, and community maternity services and enhanced home birthing services were also provided. The PRUH’s maternity service was a busy department, caring for on average 5,500 births each year. It was noted that the maternity services were being further developed. Services within neonatology were being enhanced which would allow care to be provided at the PRUH for mothers that were classed as high-risk. The Site Director of Nursing advised that they had recently appointed an experienced Head of Midwifery across the PRUH and South Sites, who worked alongside a number of matrons. The Site Chief Executive noted that a formal CQC inspection of maternity services had taken place in July 2022. The draft inspection report was still awaited, but verbal feedback received was that there were no immediate concerns.

In response to questions, the Site Director of Nursing confirmed that the data on elective caesarean section (C-section) consisted of both mothers who had underlying medical conditions and mothers who requested to have a C-section. The Site Chief Executive advised that approximately 25% of the elective C-sections undertaken were for mothers who did not have underlying medical conditions. The Site Director of Nursing said that once a patient was overdue in terms of their delivery date there was an increased risk. A C-section would sometimes be performed; however, this was not always the case and could be dependent on the induction of labor, and how it progressed. If this was not progressing, or the baby was in distress, and emergency C-section would take place.

A Member noted concerns regarding the postpartum haemorrhage (PPH) data. It was acknowledged that a comprehensive audit had since been undertaken, and suggested that this was an area that could be presented in further detail later in the year. Another Member noted that the PRUH was an outlier for PPH and enquired if the reasons for this were known, and whether it was still considered an outlier following the actions implemented. The Site Chief Executive advised that PPH data was routinely tracked and agreed that an update could be provided at a future meeting of the Sub-Committee.

The Chairman noted that Councillor Cuthbert had requested the update on maternity services, but had been unable to attend the meeting. The Site Chief Executive said he would be happy to respond to any question from Councillor Cuthbert outside of the meeting.

In response to questions, the Site Chief Executive said that robust and wide-ranging feedback was provided by patients in relation to maternity services. Some of the areas for development and review were additional birthing pools at the PRUH and for home births; and continuity of care, having the same named midwife throughout (however on occasions this needed to change if specialist care was needed). Throughout the COVID-19 pandemic, substantial feedback had been received in relation to restrictions on birthing partners, however these rules had since been lifted. It was noted that more contextual information on the feedback received could be provided at a future meeting of the Sub-Committee.

A Member noted concerns regarding the higher rate of stillbirths and birthing issues for women from Black, Asian and ethnic minorities (BAME), and enquired if more help and support could be offered during pregnancy. The Site Director of Nursing advised that this was a national phenomenon, and was not just specific to the PRUH. There were certain groups of high-risk women, and a number of specialist midwives could provide support through these specialist pathways. The Site Chief Executive noted that there were less of these issues across the borough due to the demographics, however they could draw on the skillset of staff across the Trust. The majority of experts covered both sites and patients could be referred to Denmark Hill for specific intervention. A Member considered that, in addition to social factors, stillbirths in BAME mothers could also be impacted by medical factors, with high incidents of anaemia and sickle cell disorder among this group.

The Chairman enquired if data was available in relation to multiple births. The Site Chief Executive advised that further information could be provided at the next meeting of the Sub-Committee, along with feedback on the outcome of the CQC inspection of maternity services.

The Chairman thanked the Site Chief Executive and Site Director of Nursing for their presentation to the Sub-Committee.

RESOLVED that the update be noted.