Julie Lowe, Chief Executive, will present performance information relating to hospital services.
Julie Lowe, Chief Executive presented the performance information relating to hospital services at North Middlesex University Hospital.
She referred to the CQC Inspection findings for 2014/15 following an inspection of the 8 core services and the examination of 5 aspects of care provided which was summarised in a table. She said the two key issues were for Ambulatory Care and Accident & Emergency performance.
The inspection findings gave a mixture of ‘Good’ or ‘Requires Improvement’ ratings with an overall ‘Requires Improvement’ assessment. There were 3 ‘must do’ recommendations where improvements were necessary in relation to -
· responsiveness of Outpatients department,
· training (an improvement notice was issued on this) and
· the ambulatory care environment.
In response to the findings, a Quality Improvement Plan (QIP) had been prepared and reviewed with external stakeholders. Progress had been made on the Action Plan which was detailed in the presentation.
Following on from this - ‘Quality priorities’ had been prepared for 2015/16 to improve patients’ safety and experience, and also to improve clinical effectiveness.
Julie Lowe referred to the continuing challenges and issues for the hospital especially in relation to the Accident & Emergency Service. She said this has been a serious cause of concern since July 2015. The urgent care centre opened in June 2015 and is now seeing 40% of emergencies within an hour. Performance data for the weekly 4hr target was given.
One of the reasons given for performance data was the increased number of attendances at A&E, another was due to the struggle to recruit and retain high quality doctors.
The Ambulatory Emergency Care Unit opened in October 2015. This revamped facility has resulted in an improved fast tracked service and the resulting patient feedback has been more positive. However there continues to be challenges for the A&E service, one of which is the number of patients who are ‘well enough’ and could be moved on to ‘free up’ places.
The following questions were then taken:
Q: The findings of the CQC inspection show that all core services met the ‘good’ rating for Caring aspect, however a number of services were rated ‘requires improvement’ under the ‘responsive’ and ‘well-led’ categories, does this indicate that staff are being let down by managers?
A: The ‘well-led’ category covers a number of issues and I would say for many they are doing all they can in difficult situations. Clinical leadership is an issue and more senior doctors and nurses are needed. A new medical director has been appointed to provide a lead on this, in summary we are aiming to strengthen our leadership.
Q: Would you confirm that the closure of A&E and Maternity services at Chase Farm hospital has had a detrimental impact on North Middlesex hospital, I have heard of someone who attended North Middlesex A&E department, they waited for 5 hours and eventually gave up and returned home?
A: The maternity services provided at both Barnet and North Middlesex hospitals are doing well and so too are the community based clinics and children’s centres which we should like to see open for longer hours. It should be remembered that there is good consultant cover at both maternity services at Barnet and North Middlesex hospitals which was not always possible for the maternity service when it was functioning at Chase Farm hospital. Our A& E service prioritises the people who are ‘sickest’ therefore if someone can be seen at the urgent care centre rather than A&E it is preferable that they go there. It is also better, where possible, for people to go to their GP.
Q: The CQC inspection was carried out in August 2014 do you know when this will be done again?
A: It is understood that the first round of inspections are now nearing completion, they would then move on to revisits. We are working very hard to put safeguards in place – good triage systems have been established to ensure the most urgent cases are seen first.
Q: Why does there appear to be a problem in attracting and retaining doctors at the hospital?
A: We are looking to recruit more high quality doctors. However when looking to work in A&E some doctors may prefer to work for one of the major trauma centres in London such as at the Royal London Hospital. It is very hard work for doctors at the North Middlesex hospital – which will be improved when more skilled people are fully established here. It may then be possible for a ‘buddy system’ to operate with another hospital. This is a wider problem, and not just for London.
Later in the meeting reference was also given to the high cost of housing for doctors wishing to live in the area.
Q: Is there any danger that an ‘improvement notice’ would be issued at the moment should an inspection be carried out?
A: If the CQC carried out a revisit at present there is a possibility that an improvement notice would be issued due to the overcrowded situation. Our main concern at present is to keep people safe. I was reassured the other week that findings showed that this was happening and we are keeping people safe.
Q: What progress has been made with the ‘End of Life care’ service.
A: We now have a new contract with a local hospice which has enabled us to recruit new, more palliative consultants. However there are still more people whose end of life care is in hospital when they would prefer for this to happen ‘at home’. This is something that needs to be addressed. We now have a far better advice framework for ‘end of life care’.
Q: I would have liked to see more detail of how the issues raised in the CQC Quality report are being addressed. It seems that one of the issues was the limited opportunity for clinicians and nursing staff to raise concerns.
A: The Trust’s response to the recommendations contained in the CQC Quality report is available, and this will be provided for the Health Scrutiny Workstream. It specifies the actions we are taking to improve the quality of services provided (Please note -The Risk and Quality Paper is available with the Minutes)
A Risk Summit has been called by the NHS Trust Development Authority (TDA), as the area for concern is considered as a ‘persistent issue’. The Medical Director of the TDA will chair the meeting and discussions will be held on whether the Trust is doing enough to resolve the issues. They may require us or our partners to take steps - for example we currently have 40 patients who are fit to be discharged from hospital but need to be moved elsewhere.
Q: The A & E activity levels appear to be going down, is this because people are now using the urgent care centre? Also I understand there have been fines imposed relating to contract compliance?
A: Although the overall number of people being seen at A&E is lower, the people we are now seeing are ‘sicker’ and need more care. Agency staff are being used to help provide cover, however, there are advantages in employing people from the local area.
Fines imposed have been unhelpful. However, there have been no reductions in funding for A&E services resulting from this.
McKenzie Health had been brought in and had focused on areas where improvements could be made. This had included efforts to identify patients for discharge, so that transport could be organized to enable patients to leave earlier in the day. Also they looked at the triage service to help in the earlier identification of cases where chest pain was an issue.
Q: It may be that a number of residents for both Enfield and Haringey are not registered with a G.P or if they are then perhaps they give up attempting to see their GP and therefore go to A & E?
A: This is not my remit but agree that this may be the case and that people would have made a choice to go directly to hospital.
Q: Following on from the CQC report and management/ staffing concerns what has happened regarding the management structure for all Departments, not just for A&E?
A: In terms of management - at Department level we have a full cohort which was not the case before. They have experience and are more stable and more established. We have also invested in Nurse leadership with more senior nursing support now in place. The new Medical Director has been appointed and a new HR Director has carried out work on subjects such as ‘vision management’ and ‘staff values’. We have also recruited new consultants, who are younger and who may need more support. It is a work in progress.
Questions from a member of the public
Q: It is important that a senior nurse be present at ‘Triage’ who would immediately assess people as they arrive and send them directly to x ray where this is appropriate
A: This is done as much as possible, perhaps not as much as we would like.
Q: I think North Middlesex hospital should be classed as a ‘Trauma’ hospital and also it would be helpful if there was a ‘Triage’ service at Chase Farm hospital.
A: Major trauma hospitals are where vascular and neuro surgery is performed.
Q: It is unfortunate that nursing quarters have been lost at Chase Farm hospital as this would make it much easier to recruit nursing staff.
In my experience it is difficult to get to see a doctor and there are a lot of people who are not registered with a doctor who would go directly to hospital if they have a medical problem.
A: Accommodation for single nurses is not usually a problem, the main cause for concern is when housing needs to be found for the family.
Councillor Abdullahi asked –
Q: If a further CQC inspection was carried out in a year’s time how confident would you be that the main issues for the Trust had been remedied?
A: We are determined that we must improve and for this to be done this year. Some challenges are not quick fixes and we will need the support of our partners. This is what people in Enfield deserve.
Julie Lowe and Council Members from Haringey were thanked for attending the meeting.