Brighton & Hove City Council
Health Overview & Scrutiny Committee
4.00pm19 October 2022
Council Chamber, Hove Town Hall
MINUTES
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Present: Councillor Moonan (Chair)
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Also in attendance: Councillor West (Group Spokesperson), Grimshaw, O'Quinn and Rainey
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Other Members present: Geoffrey Bowden (Healthwatch), Michael Whitty (Older People’s Council), Nora Mzaoui (Community & Voluntary Sector)
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PART ONE
10 Apologies and Declarations of Interest
10.1 There were no substitutes
10.2 Apologies were received from Cllr John.
10.3 There were no declarations of interest.
10.4 RESOLVED – that the press & public be not excluded from the meeting.
11 Minutes
11.1 RESOLVED – that the minutes of the 13 July 2022 committee meeting were agreed as an accurate record.
12 Chairs Communications
12.1 The Chair gave the following communications:
Firstly, I would like to say a few words about the recent passing away of Cllr Garry Peltzer-Dunn. Garry was one of our longest serving members, having first been elected to Hove Borough Council in 1971. Garry had an illustrious career as a Cllr, service two terms as Leader of Hove, and a year as Mayor of Brighton & Hove in 2008. Amongst the many roles Garry was Chair of HOSC.
Secondly, I would like to encourage everyone who’s eligible to get a free flu vaccine or Covid autumn booster to book theirs as soon as possible.
We’re seeing a rise in positive Covid cases in Brighton & Hove and unfortunately the number of patients in hospital with COVID-19 is also increasing. Getting an autumn booster will help to improve your protection against severe illness from Covid. They are now available for everyone over 50, as well as people who are more at risk and those that live or work with people who are vulnerable. You can book an appointment online or by calling 119.
And if you haven’t had your first or second vaccine, please know that they are still available too.
Alongside Covid, more people are likely to get flu this year as fewer people have built up a natural immunity to it during the pandemic. The NHS is currently offering the flu vaccination for free to anyone who is more at risk. This includes many children, everyone aged 50 or over, those with and underlying health condition and those that live with, work with or care for those who are more at risk. To get yours you’ll need to make an appointment with your GP or participating pharmacy.
Thirdly, some comments about today’s agenda:
As members will recall, we had a paper on locally commissioned Trans health services at the July HOSC, and were planning a second paper at this meeting focusing on more specialist services commissioned by NHSE. However, the procurement of Sussex-wide Trans services is still ongoing which means NHSE cannot discuss details at a committee meeting. I have therefore deferred this item until November.
At the last meeting we had a member question on cancer screening, and the committee agreed we would have an item on screening at committee. This will also be at the November HOSC meeting – we will cover the national screening programmes for breast and cervical cancer as well as take-up of the HPV vaccination.
It was also agreed at the last HOSC that we would invite the CEO of Southern Water to a future meeting. He has been invited to attend the January 2023 HOSC.
Finally, today’s agenda is focused on University Hospitals Sussex, with papers on the CQC inspection of surgery and maternity, on the CQC inspection of urgent & emergency services and on the 3Ts development of the Royal Sussex. I’m pleased to say that we will be joined by the Trust’s Chief Executive, Dr George Findlay, for the CQC items. However, Dr Findlay will have to leave at some point for another meeting. To make the most of his attendance, I propose that we hear from Dr Findlay about surgery, urgent & emergency services, and upper gastro-intestinal cancer surgery. There will then be an opportunity to ask Dr Findlay questions about these services. We will subsequently hear from Dr Maggie Davies, Chief Nursing & Midwifery Officer, on maternity and there will be an opportunity to question Maggie.
I appreciate that this is a slightly different order than the one set out in the agenda reports, but I trust it won’t prove too confusing.
13 Public Involvement
13.1 There were no public questions.
14 Items Referred from Council
14.1 There were no items referred from Council.
15 Member Involvement
15.1 There were no member involvement items.
16 Care Quality Commission Inspection Report on Maternity and Surgical Services at the Royal Sussex County Hospital: Update
16.1 The Chair told members that she had agreed that items 16 and 17 would be jointly presented, as both concern Care Quality Commission (CQC) inspections of University Hospitals Sussex NHS Foundation Trust (UHSx) services.
16.2 Dr George Findlay, Chief Executive of UHSx, and Dr Maggie Davies, UHSx Chief Nursing & Midwifery Officer, presented on items 16 and 17.
General Issues
16.3 Dr Findlay told the committee that UHSx manages seven hospitals across Sussex, including acute hospitals in Chichester, Worthing and Hayward’s Heath and the Royal Sussex County Hospital (RSCH) in Brighton. In September 2021, the CQC undertook an inspection of maternity services in all of these hospitals, and additionally of surgery at RSCH. The CQC published its findings in January 2022, downgrading its rating for maternity at all Trust hospitals, and for surgery at RSCH. The CQC re-inspected in April 2022, and simultaneously conducted an inspection of RSCH urgent & emergency services. It published inspection reports in July 2022, noting some improvements in RSCH surgery but with unchanged ratings; and downgrading its rating of urgent & emergency services at RSCH.
16.4 The downgrading of CQC ratings of hospital services is disappointing, but needs to be seen in the context of national pressures: Sussex hospitals remain comparatively good. Following the CQC reports, significant improvements made to maternity services. There has been less improvement in terms of surgery and urgent & emergency, but the capacity issues at RSCH have a major impact on these services. It is important to stress that staff across the Trust are amazing, a fact recognised by the CQC.
16.5 Cllr Grimshaw asked a question about what the Trust was doing about staff accommodation, noting that she had spoken to an NHS worker who had been unable to find a room in a shared house in the city. Dr Findlay acknowledged that the cost of living in Brighton & Hove poses a significant challenge. The Trust has limited staff accommodation, but this needs to be reserved for newly recruited staff moving in from another area. UHSx is working closely with charities and Housing Associations to support staff through the cost of living crisis.
16.6 Cllr O’Quinn asked why BAME staff experiences were not mentioned in the CQC inspection report. Dr Findlay responded that the CQC had found no issues with BAME staff in its inspection. However, the Trust recognises that, as with any other large employer, it needs to improve experiences for BAME staff and this is a key improvement workstream.
16.7 Cllr O’Quinn enquired about the UHSx attitude to overseas recruitment, given that there has been criticism by the WHO on the negative impact this has on health systems in the developing world. Dr Findlay replied that UHSussex actively recruits oversees staff, in accordance with Government policy. The Trust is proud of the measures taken to integrate oversees workers into the workforce. The Trust is also proud of the work it does with local universities, including Chichester, to develop local talent in areas such as nursing and allied health professions. Dr Davies added that Chichester runs a more traditional nurse training course than many universities, with a focus on supporting students with an aptitude for nursing rather than people with high A level results.
16.7 In response to a question from Cllr O’Quinn about the Trust’s lack of improvement progress in recent years, Dr Findlay argued that this was inaccurate: Brighton & Sussex Universities Trust had seen major improvement in 2018, when its CQC rating was increased. Services remain generally good despite the very severe pressures caused by Covid.
16.8 Cllr O’Quinn asked a question about the Trust’s use of agency staff. Dr Davies responded that UHSx aspires to use agency staff only for specialist roles, hence the focus on local and international recruitment of permanent staff.
16.9 Cllr West asked a question about staff retention rates and about support for staff welfare. Dr Findlay responded that staff retention rates are good, although there is more work to be done, particularly with Band 2 Healthcare Associates. The Trust offers all staff wellbeing appraisals and will signpost staff to independent financial advice, foodbanks etc. UHSx provides some limited direct financial support to staff.
16.10 Geoffrey Bowden commented that Healthwatch had contributed to the recently published CQC reports, and also to two further inspections: of leadership across the Trust and of neurosurgery. Dr Findlay told members that neither inspection report has yet been published, but that feedback from the CQC has been positive, particularly for neurosurgical services.
16.11 The Chair asked why RSCH underperforms other UHSx hospitals. Dr Findlay replied that the core problem is that the RSCH site is too small for the level of demand. The hospital is consequently cramped and overcrowded, and this inevitably impacts on care and leads to frustrated staff who are unable to deliver the care they want to. The multi-million pound redevelopment of the front half of the RSCH site, known as 3Ts will help in this respect.
Urgent & Emergency
16.12 Dr Findlay told the committee that urgent & emergency services at RSCH had been downgraded from ‘good’ to ‘requires improvement.’ This was because of concerns about safety, largely due to overcrowding in the emergency department. This was a fair comment by the CQC, and is something being seen across the country. UHSx has done what it can to manage emergency department pressures: e.g. by opening an Urgent Treatment Centre (UTC), and remodelling the emergency department; but overcrowding remains a major issue. Staff have responded positively to the CQC report, and work is ongoing internally to improve flow through the hospital by reducing length of stay, and externally by working with partners to minimise discharge delays.
16.13 Nora Mzaoui asked why such high numbers of people with mental health issues were presenting for treatment at A&E. Was this due to local demographics, or a lack of mental health system capacity? Dr Findlay acknowledged that this is a real problem, both in terms of people presenting for treatment and in terms of the police bringing S136 detainees to A&E as a place of safety. Sussex Partnership NHS Foundation Trust (SPFT) is working to improve city mental health prevention and crisis services, and UHSx is also planning to open a dedicated mental health facility on the RSCH site, to be staffed by SPFT. This is planned to open by Christmas. These measures should help, but the growing number of mental health presentations is also likely to reflect increasing problems with mental health across the population.
16.14 Cllr Grimshaw told members that an elderly resident in her ward had experienced poor care at RSCH, being directed to the UTC after a long wait in A&E and then redirected to A&E after waiting in the UTC. Dr Findlay responded that things had clearly gone wrong for this patient, who should have been either dealt with by primary care services or signposted by the A&E streaming nurses. Work is also needed on a better interface between primary and secondary care services. This will be advanced via the Sussex Integrated Care Board (ICB).
16.5 Cllr Rainey asked whether there was a need for more staff training to deal with people with mental health problems or multiple health needs seeking support. Dr Findlay responded that we are in uncharted waters in terms of the increase in mental health issues. UHSx is working closely with SPFT, and lots of staff training is available. However, the Trust does not want to normalise a situation where A&E becomes the default destination for people in mental health crisis as this is not how the system is intended to function.
16.6 Cllr Rainey suggested that the mental health pressures faced by A&E indicated a need for more acute mental health beds. Dr Findlay replied that he did not disagree, but this was not something for him to determine as UHSx is not the provider of mental health services locally.
16.7 The Chair asked whether this winter was set to be unusually bad. Dr Findlay responded that every winter was challenging, but there were particular concerns for the coming winter in terms of staff resilience. There is a comprehensive winter plan to minimise admissions, provide additional bed capacity and reduce length of stay. Discharge delays are a real problem: at any given point between 10 and 25% of beds are occupied by patients who are medically ready for discharge but who are awaiting care packages. There is also a system focus, led by Sussex Community NHS Foundation Trust (SCFT), on supporting frail people and providing anticipatory care to avoid admissions.
16.8 In response to a query from the Chair on the Trust’s performance against A&E targets, Dr Findlay told members that the current focus was on safety rather than targets. For information, the RSCH is currently reporting around 55% against the A&E target of 90% of patients seen within 4 hours. There are also numerous 12 and 24 hour breaches, and patient feedback is poor, with only around 75% of patients who would recommend urgent & emergency. This is just the reality of the current pressures being faced by the NHS.
Surgery
16.9 Dr Findlay told the committee that there had been improvements in surgery following the CQC inspection report, with particular progress in infection control, incident management and recruitment. UHSx has commissioned external reviews of aspects of surgical services to help identify factors blocking improvement. Dr Findlay also told members that upper GI (gastro-intestinal tract) cancer surgery had been suspended at RSCH following a CQC report. This affects only a small number of patients, with other upper GI treatments continuing as normal. Patients due for surgery have been redirected to the Royal Surrey in Guildford, with no delays to treatment. The CQC had been particularly concerned with levels of staffing at RSCH, although no unit in South-East England meets staffing requirements for upper GI and outcomes at RSCH had been good (the Trust commissioned an independent review of outcomes since 2019 to establish this). UHSx hopes to resume upper GI surgery at RSCH as soon as possible.
16.10 The Chair asked a question about the 3Ts development of RSCH as a tertiary centre, and whether this could be achieved without a negative impact on secondary services for city residents. Dr Findlay replied that he would not have personally chosen to name the development programme 3Ts (tertiary, teaching, trauma) as this gives the impression that it is focused on specialised services, whereas phase 1 of 3Ts is actually mostly focused on improving secondary services. There is a need to grow tertiary capacity in Sussex: currently more than 50% of patients requiring cardiac or neurosurgery have to travel to London or Southampton. However, the Trust is committed to providing secondary services for local people.
16.11 In response to a question from Cllr West on the threat of a ‘twin-demic’ this winter, Dr Findlay responded that this is something that the Trust is modelling. There is a particular focus on protecting planned (elective) procedures: e.g. working with Queen Victoria Hospital, East Grinstead, Eastbourne General Hospital and local independent sector providers to ensure that there is sufficient capacity to run the planned elective programme.
16.12 The Chair thanked Dr Findlay for his attendance, and also thanked everyone working locally in the NHS for their hard work and dedication.
Maternity
16.13 Dr Davies told the committee that there has been significant improvement in maternity services following the CQC report. Staffing levels have improved across the Trust, although it remains more difficult to recruit to Brighton & Hove due to cost of living issues. There is a good career offer for midwives, with the range of different maternity environments across UHSx hospitals, including the Trevor Mann intensive care unit, providing an attractive range of settings. A new Director of Midwifery has been appointed; sickness levels have decreased; weekly listening events have been implemented; a better maternity information system has been launched; there have been no recent ‘never events’; and staff morale has improved. There is still more work to be done, however.
16.14 In response to a question from Cllr Grimshaw on the role of the Director of Midwifery and on staffing, Dr Davies told members that the Director works across all four hospital maternity units, with a matron in operational charge of each site. The Trust has had recent successes in recruiting nationally and internationally for midwives, maternity support workers and maternity workers. Worthing and Chichester maternity units are currently at establishment. Dr Davies promised to circulate the figures for Brighton & Hove.
16.15 In answer to a query from the Chair about midwife to mother ratios, Dr Davies agreed that this was an important metric. The Trust holds daily huddles and will move staff between sites to maintain a good ratio in each unit, including one-to-one support for mothers in labour etc.
16.16 In response to a question from Cllr O’Quinn about staffing mix, Dr Davies responded that the Trust aims to have a good mix of experienced and more recently qualified staff, with active recruitment at both ends of the experience scale. There is a focus on retaining staff and on ensuring that midwives in training continue to work at the Trust once qualified.
16.17 Geoffrey Bowden noted that Healthwatch had been asked to undertake a pilot study of mental health and maternity.
16.18 In response to a question from the Chair on 24/7 staffing levels, Dr Davies told members that there is a focus on maintaining safe staffing levels at nights and weekends. Staffing levels are not constant throughout the day and week as elective procedures tend to be scheduled for daytime in the working week. The Trust does its utmost to maintain rotas on all its sites, although this can be a challenge, particularly when staff report sick at short notice.
16.19 In reply to a question from the Chair about the institution of a listening culture, Dr Davies told members that there has been a good deal of work in this area, with listening events, senior officers maintaining an open door policy, a Non-Executive Director meeting each month with maternity staff, and a route for all staff to raise concerns directly with the Chief Nursing Officer. There have been concrete improvements in response to staff feedback, including improved staff rest areas.
16.20 The Chair thanked Dr Davies for her presentation.
16.21 RESOLVED – that the report be noted.
17 Care Quality Commission Inspection Report: Accident & Emergency at the Royal Sussex County Hospital
17.1 This item was taken together with item 16 and member comments and questions are detailed in the minute to item 16.
17.2 RESOLVED – that the report be noted.
18 3Ts Redevelopment of the Royal Sussex County Hospital
18.1 This item was presented by Karen Geoghegan, UHSx Chief Financial Officer, and by Peter Larsen-Disney, Clinical Director for the 3Ts Programme.
18.2 Ms Geoghegan told the committee that the full business case for 3Ts had been agreed in 2015. 3Ts has been a programme to develop the Royal Sussex County Hospital (RSCH) as a regional tertiary, trauma and teaching hospital. The programme has three phases: phase 1 involves the redevelopment of the Barry building to provide a trauma centre and improved wards (due to open in 2023); phase 2, a new cancer centre (opening in 2025); phase 3, a new logistics centre (opening in 2026). In all 3Ts will involve the creation of 100+ new beds and new specialist facilities at an overall cost of around £750 million. 3Ts is part of the Government’s 40 Hospitals Programme. Phase 1 buildings will become available in November 2022, with a pre-occupation stage from November to January 2023, followed by services moving across in February/March 2023, and then preparation for phase 2.
18.3 Mr Larsen-Disney told members that he is proud of the new facilities: moving from having the oldest clinical estate in the NHS to the newest is a fantastic thing and will have a massive positive impact on patients, especially in terms of the privacy and dignity that can be accorded to them, with lots more room around beds and around 60% of beds to be in single ensuite rooms, many with sea views. Outpatient facilities have also been significantly improved, with street level access, better waiting rooms, shops, a bus stop directly outside the unit, better car parking (with 150 new spaces for patients and visitors) etc. Lots of thought has been given to the patient journey across the site, with lifts positioned at the front of the building so people can go directly to the floor they require. The new buildings will be very energy efficient.
18.4 3Ts will benefit staff also, creating a much improved work environment as well as offering lots of new job opportunities. There will be a focus on developing smarter job roles with greater opportunities for career progression: e.g. finding innovative uses for pharmacists, physician assistants etc.
18.5 3Ts presents an opportunity to rethink the delivery of acute care and there is an ongoing regional review of critical care capacity, involving a shift-change in thinking about clinical pathways and patient journeys. This will involve more focus on ambulatory care and short-term admissions; the development of a frailty unit; development of better sub-critical care acute respiratory support; and rapid stroke assessment and access to thrombolysis. There has also been a focus on the physical lay-out of services within the hospital: e.g. a new CT scanner has been located in ITU, which will eliminate the need to move critically ill patients around the hospital to access scanning.
18.6 Ms Geoghegan added that there has been extensive engagement with local people, with a liaison group in operation since 2009. HOSC members will be invited to visit the phase 1 site.
18.7 Cllr West commended the achievement to deliver 3Ts and noted the positive impact it would have. However, he had concerns about pressures caused by additional car journeys to and from the site and about the provision of public transport. It was particularly unfortunate that there was no covered interchange for bus travellers. Mr Larsen-Disney responded that the Trust encourages sustainable travel, but it is inevitable that many sick people will want or need to drive to the RSCH, and it is very difficult for people to do so currently given the limited parking availability. UHSx has made a conscious effort to improve traffic flow around the hospital site, but has limited influence on what is essentially an issue for the city council. Ms Geoghegan added that there was a limit to the facilities for bus travellers that could be provided on the RSCH site, but that there were screens in the foyer providing regularly updated bus information, so people can wait for buses in the warm.
18.8 Cllr West asked a question about the sustainability of the 3Ts build. Ms Geoghegan replied that sustainability has been a core element of the development, with lots of recycling and use of recycled materials. Much of the development has involved modular buildings constructed off site. This significantly reduces traffic in and out of the site.
18.9 Geoffrey Bowden noted that he had been a member of the BHCC Planning Committee that had approved the original 3Ts application. He asked what the building would look like in 10 years’ time. Ms Geoghegan responded that really high specification materials have been used in the build which means it will continue to look good for many years. However, it will require maintenance, including a substantial amount of window cleaning.
18.10 Mr Bowden asked a question about use of the helipad. Mr Larsen-Disney responded that there would be around 50-100 flights per year. There are no restrictions on when helicopters can land, although wind factors may restrict landings.
18.11 Cllr Grimshaw asked how a development only providing around 100 new beds could cost £750 million. Mr Larsen-Disney responded that Phase 1 of 3Ts would take patients out of other parts of the hospital, freeing up space in other departments which could be used to expand or otherwise improve services. In addition, the Trust is focused on reducing the length of bed stays: e.g. people typically spent 10 days in hospital recovering from major surgery, but this has now been reduced to an average of 4-5 days. This is of great benefit to patients, particularly to elderly and frail patients where there are real risks associated with being bed-bound for long periods of time. This focus, which will be supported by the new RSCH environment, means that there is not necessarily a need to significantly increase the number of beds at the hospital. It should also be recognised that 3Ts is only one part of the improvement picture. For example, investment in A&E will be needed to deal with overcrowding. Ms Geoghegan added that the improved layout of beds in the Phase 1 rebuild will increase the clinical effectiveness of care and play a part in reducing length of stay. It should be noted that there will not be a short-term increase of 100 beds, as not all will be opened immediately and there will be issues with staffing etc. However, the completion of Phase 1 will allow the decant of patients from other parts of the hospital which will allow the Trust to move at pace with its plans to redevelop the emergency department.
18.12 The Chair asked how many new beds would be available when Phase 1 comes into operation in Spring 2023, and how many of these would be for city residents? Mr Larsen-Disney responded that on day one of Phase 1 opening to patients there will be around 50 extra unallocated beds. 24 of these will be critical care beds, so could in theory be filled by patients from anywhere in the region. However, most of the decant of patients into the Phase 1 build is from the Barry and Courtyard buildings, which mostly provide local services.
18.13 In response to a question from Cllr O’Quinn on private beds, Ms Geoghegan assured members that there will be no private beds in the new Stage One hospital building.
18.14 In answer to a query from Cllr Rainey on local food sourcing and sustainability, Ms Geoghegan told the committee that there has been lots of focus in 3Ts on ensuring that cafes offer healthy eating options and minimise the use of plastics etc. In terms of patient food, the ambition is to use the kitchen facilities at St Richards Hospital, Chichester, to provide for all UHSx sites. This would mean all hospital food being made in Sussex, a major advance in terms of carbon footprint and localism.
18.15 In response to a question from Cllr Grimshaw on whether there is always enough food for patients, Ms Geoghegan confirmed that there is always enough reserve food and that robust contingency plans are in place for emergencies.
18.16 Geoffrey Bowden asked what the per meal budget was for hospital food. Ms Geoghegan did not have the figure to hand but promised to provide a written response.
18.17 Cllr West noted that he understood the argument that a focus on lessening length of stay would reduce the demand for beds. However, when would the system know that 3Ts is working in this way? Mr Larsen-Disney responded that it was difficult to give a timeline for this, but the principle is widely accepted with lots of evidence of it working from other places.
18.18 In response to a question from Cllr West on fresh air in the hospital, Mr Larsen-Disney confirmed that the new facilities will have much better access to ventilation than the buildings they replace.
18.19 The Chair asked a question about flow through the hospital and problems with discharge delays. Mr Larsen-Disney responded that the Trust works hard with the city council, Sussex Community NHS Foundation Trust and other partners on discharge. 3Ts will assist in this work by reducing length of stay, meaning that patients will be at less risk of becoming deconditioned through lengthy bed stays, and less likely to need extensive care packages on discharge.
18.20 The Chair thanked the presenters for their contributions and noted that, although the local health and care system faces considerable challenges, the 3Ts development offers exciting opportunities for the city.
18.21 RESOLVED – that the report be noted.
The meeting concluded at Time Not Specified
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Signed
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