Agenda item - CQC Inspection of Brighton & Sussex University Hospitals Trust (BSUH)

26.1    The Chair introduced the main agenda item:

“Moving on to the main item of business, you’ll all be aware that the CQC inspected the hospital trust back in April. The CQC issued a Section 29a notice in June this year, listing changes that BSUH had to make urgently. The full inspection report followed in August, and there was a Quality Summit where the CQC and BSUH presented the report’s findings to key local stakeholders. The CQC report rated the trust as inadequate and it was placed in special measures by the trust regulator, NHS Improvement.

I wanted to give BSUH the opportunity to respond to the CQC report; to explain what actions it has already taken in response to the Section 29a notice and to the findings of the CQC inspection report; and to describe its plans to further improve quality, safety and performance.

I’d therefore like to welcome Tony Kildare, Interim Chair of BSUH; Dr Gillian Fairfield, the Trust Chief Executive; Dr Steve Holmberg, the Medical Director; and Lois Howell, Director of Clinical Governance.

Before we start I’d like to stress that scrutinising the improvements required by the CQC report on BSUH is going to be a long and complex task – this meeting is just the start of the process. However, it’s important to be clear that it isn’t the HOSC’s job to come up with ways to improve performance or quality at the trust – there are plenty of people already working on this. Our role is to monitor the implementation of improvement planning to ensure that the promised changes are being made – and crucially to check that changes actually lead to better services for local people.

We all recognise that the CQC report is pretty disturbing – lots needs to change at BSUH and it needs to change quickly. It is the job of HOSCs to make sure that the required changes do take place and to escalate our concerns if they don’t. However, it is also important to recognise that the trust does lots of amazing work and has really dedicated and caring staff. We’re here to be a critical friend to BSUH and to assist its vital improvement work.

Finally, although CQC reports focus on individual organisations, it’s important to recognise that many of the issues facing BSUH are system problems and will require system solutions. The hospital alone can’t resolve problems like Delayed Transfers of Care. When we focus on the implementation of quality improvement measures, we’re going to need to look, not just at BSUH, but at the whole of the local health and care system.”

26.2    Lois Howell (LH) gave a PowerPoint presentation on the CQC inspection and on the trust’s quality and safety improvement work. (A copy of the presentation slides is included for information in the document packs for the 05 October 2016 and the 19 October 2016 HOSC meetings.) Trust representatives then answered member questions.

26.3    In response to a question from Cllr Marsh on the role of the NHS Improvement (NHSi) appointed Improvement Director, Dr Fairfield (GF) told members that the Director would offer the trust advice and support for its improvement work. Typically an Improvement Director will take responsibility for developing a trust’s quality improvement action plan in response to the CQC’s findings. However, BSUH had already developed its own Quality & Safety Improvement Programme before the appointment of the Improvement Director because the trust had advance notice of some of the CQC’s findings via the Section 29a warning it was issued in June this year.

26.4    In response to a question from Cllr Marsh on when substantive appointments for trust Chair and Chief Executive would be made, Mr Kildare (AK) told the committee that there was no date set for these appointments. It is likely that the Chair will be appointed first, with the Chair and the Board then appointing a Chief Executive in the normal manner. AK stressed that there had been considerable recent change in the composition of the Board, with several new Non-Executive Directors joining.

26.5    In answer to a question from Cllr Marsh about recruitment, GF told members that the trust was seeking to recruit following CQC criticism of the medical staffing mix in the Emergency Department (ED) at the Princess Royal Hospital (PRH). However, BSUH is also trying to clarify the CQC’s position on this point, as the trust believes that its current level of consultant-grade staffing is an appropriate one given the nature of the PRH ED. It may be that BSUH is able to recruit additional medics at Senior House Officer (SHO) grade rather than consultants.

26.6    Cllr Miller noted that, unlike NHS Foundation Trusts (FT) which have a Council of Governors to scrutinise the trust’s Board, BSUH appears unduly reliant on the Board’s ability to hold itself to account on a day to day basis. GF responded that Non-Executive Directors have a key role to play here in holding the trust’s executive to account. The point about the lack in non-FT NHS trusts of the equivalent of a Council of Governors is a valid one. It is important that key stakeholders such as HOSCs, Healthwatch and the User & Carer Forum act to hold the trust to account. Cllr Russell-Moyle suggested that it would be useful for HOSC members to meet BSUH Board members. GF agreed and offered to host a future HOSC meeting which could be combined with a tour of the hospital and the opportunity to meet Board members. HOSC members welcomed this offer.

26.7    In response to a question from Cllr Miller as to whether the trust needed more bed capacity, GF agreed that this would be helpful, noting that options are being explored via the Sustainability & Transformation Plan (STP) programme. BSUH is also looking at the use of additional modular buildings at PRH. Dr Holmberg (SH) added that it was particularly important to find more space for ambulatory care as this can offer an alternative to admission.

26.8    In answer to a question on staff absence rates and general staff morale, GF told the committee that the staff absence rate was currently 4.2% against a target of 3%. The trust is committed to working more closely with staff and plans to survey all staff this year to garner their views. Other innovative measures to engage with staff are also planned.

26.9    In response to a question from Cllr Russell-Moyle as to whether the trust has the right staff in place to make the move from inadequate to excellent, GF told members that it was important to bring in fresh staff with experience of working in excellent organisations and staff with experience of improving failing organisations. GF noted that she had previously successfully led two trusts through the FT pipeline as well as being the Chief Executive of trusts which have achieved outstanding CQC reports. The trust has also recently recruited Lois Howell as Director of Clinical Governance and is seeking to recruit a new Executive HR Director. However, it is also crucial that the trust retains its organisational memory.

26.10  Cllr Russell-Moyle also queried what the impact of the recent reduction in neurological trauma bed capacity had been. SH told members that the CQC had identified problems with neurological intensive care staffing. This was a consequence of the recent re-siting of these services at RSCH (from PRH): some staff had opted not to make the move and the trust was still in the process of recruiting/training to fill this gap. In the interim BSUH has decided to temporarily close one neurological bed. This has had some impact on elective waiting times, but not on emergency performance, as this takes priority over planned procedures. BSUH works closely with the neurological trauma departments in Southampton; St Georges, Tooting; and King’s hospitals, and patients would be diverted to one of these centres should there be no capacity at RSCH. There is increasing demand for this service following the re-siting and the trust plans to expand provision.

26.11  In response to a question from Cllr Russell-Moyle on recruitment, SH told members that there were national problems in recruiting to certain specialities, particularly emergency medicine, pathology and care of the elderly. LH added that there are particular local challenges posed by the cost of living in Brighton & Hove. Many BSUH staff (particularly non-medical staff) do not live in the city, instead travelling into work from across East and West Sussex. This can make staff retention difficult as people are tempted by work that is nearer their homes. It can also make persuading staff to work additional hours problematic, as some staff who are willing to take on additional work find it easier and more remunerative to travel to London to do so. AK noted that it was important that the trust does all that it can to persuade its own medical students to make careers in the city.

26.12  Cllr Wealls noted that the CQC report was particularly damning about BSUH organisational culture and wondered how this might be improved. GF agreed that this was a very significant challenge. In the past the Board has been too remote from staff and there needs to be much better engagement. There is a workforce programme in place to change the culture, although this is not a short term process and may take five years or more to turn around. The trust also recognises the CQC’s criticisms of its handling of Black & Minority Ethnic (BME) staff and aims to do more in terms of supporting BME workers and indeed all workers with protected characteristics. AK added that the Board was committed to doing much more to engage with staff, including a staff forum, Board members and senior managers engaging in ‘ward rounds’, and the emailed ‘Monday Message’ to all staff.

26.13  In response to a question from Cllr Wealls as to whether the trust has sufficient funding given the size of its 15/16 deficit (C£40M), GF told the committee that it was too early to say what the 16/17 position would be. However, the trust is doing a good deal of work to increase its efficiency – mostly incrementally via making small improvements in day to day processes across a very wide range of services.

26.14  In response to a question from Cllr Wealls about the feasibility of making the required quality improvements whilst also delivering the 3T programme, GF acknowledged the scale of the task. The two projects must be treated as functionally discrete, as hospital services have to continue as normal despite 3T. However, there are obvious ties between 3T and aspects of BSUH’s improvement work – e.g. workforce modernisation has to be responsive to the opportunities and demands presented by 3T. There is a good deal of Treasury oversight of the 3Ts work as it is a very significant NHS capital project.

26.15  In response to a question from Cllr Mac Cafferty on staff disengagement and on whistle-blowing arrangements, LH told the committee that this was being addressed via changes to BSUH’s clinical governance structures, by increasing senior manager ward presence, and by innovations such as the Clinical Council. In terms of whistle-blowing, the trust is in the process of appointing an independent ‘Speak-Up Guardian’ to support staff. GF added that she has started to get staff coming directly to her with whistle-blowing concerns, which is a positive development.

26.16  In answer to a question from Cllr Mac Cafferty on co-working with other NHS organisations, AK told the committee that the trust was committed to work positively with its partners. GF added that BSUH is actively engaged with the STP process. There have been recent problems with co-working, for example around Patient Transport services, but the trust has worked positively with Brighton & Hove CCG to address these concerns.

26.17  Cllr Mac Cafferty noted that the BSUH quality improvement programme was an important issue and it would be helpful to find some way of making more elected members aware of it and of the steps being taken to improve quality and safety at the trust.

26.18  Colin Vincent (Older People’s Council representative) expressed concerns about incidents identified by the CQC where patients’ privacy and dignity had been severely compromised. GF said that these incidents were totally unacceptable and that much has subsequently been done to ensure that patients are accorded privacy and dignity – e.g. the introduction of comfort rounds for people waiting in the ED.

26.19  Mr Vincent expressed concern about levels of Delayed Transfers of care (DToC) from BSUH beds back into the community. SH noted that this was a very complex matter. The ambition is for patients to experience a seamless transition from hospital back to the community, but this is complicated because this is a multi-agency issue. However, it ought to be possible to develop a single-assessment tool accepted by all the agencies involved. There is a good deal of work being undertaken to address DToC – for example the Hospital at Home programme. This was initiated at a fairly small scale, but will be scaled-up.

26.20  In response to a question from Mr Vincent about the size of RSCH A&E, GF told members that an additional four cubicles have recently been added to A&E and there are plans to restructure the department to free yet more space.

26.21  Cllr Turner (Chair of West Sussex Health & Adult Social Care Scrutiny Committee) told members that the HASC had already considered this issue, but that the additional information supplied by BSUH for this meeting was useful. Cllr Turner also noted that it was challenging to scrutinise BSUH from Chichester – the distance involved made considerable demands on the time of BSUH staff. He therefore welcomed proposals for Sussex HOSC to jointly monitor BSUH’s improvement work.

26.22  In response to a question from Cllr Turner as to how BSUH’s improvement planning was linked to outcomes, LH assured members that outcomes measures would play a significant role in the indicators identified to measure the success of the improvement programmes. SH added that mortality indicators also have an important role to play in assessing the success of trust services.

26.23  Cllr Deane stated that it was quite proper that the HOSC should act as a critical friend to BSUH. However, it was important that the trust should be candid with the HOSC. In the past the trust has been over-optimistic about its ability to improve services.

26.24  Cllr Cattell enquired about the possibility of some estates held by BSUH being used for key worker housing, thereby helping to improve the recruitment situation. AK responded that unfortunately the trust has no spare estates – the very small amount of free land it did have is being used to facilitate the 3Ts build.

26.25  In response to a question from Cllr Cattell on electronic prescribing, SH told the committee that electronic prescribing has been introduced for discharge medications, but in-hospital and outpatient prescribing are still paper-based.

26.26  In response to a question on the use of long term prescriptions, SH told members that there was a difficult balance to be struck here. BSUH medics are comfortable with long term (i.e. 6 month) prescriptions, but national guidance is increasingly for much shorter term periods.

26.27  RESOLVED -That members note the general information on the CQC inspection process and specific information relating to the BSUH inspection included in this report and its appendix; and that

Members agree to appoint three members to an informal joint HOSC working group to monitor the implementation of quality improvement planning in response to the CQC’s recommendations.