Agenda item

(To receive a report from Jan Sobieraj (Chief Executive – United Lincolnshire Hospitals NHS Trust) which provides an update on progress against ULHT Improvement Portfolio and gives an overview of action being taken where risks and issues have been identified. The report also describes the governance arrangement which have been put in place.  Jan Sobieraj (Chief Executive – United Lincolnshire Hospitals NHS Trust) will be in attendance for this item)

At this point of the proceedings, Councillor G Gregory advised the Committee that he had rotated to Sherwood Forest Hospitals NHS Trust and was no longer a paid employee of United Lincolnshire Hospitals NHS Trust (ULHT).  He therefore no longer had a pecuniary interest to declare for any item of business relating to the ULHT.

 

A report by Jan Sobieraj (Chief Executive – United Lincolnshire Hospitals NHS Trust) was considered which provided an update on progress against the ULHT Improvement Portfolio and gave an overview of action being taken where risk and issues had been identified.  The governance arrangements which had been put in place were also described.

 

Jan Sobieraj (Chief Executive – United Lincolnshire Hospitals NHS Trust), Mark Brassington (Chief Operating Officer – United Lincolnshire Hospitals NHS Trust) and Liz Ball (Deputy Chief Nurse – United Lincolnshire Hospitals NHS Trust) were all in attendance for this item of business.

 

Members were advised that the four key recovery work streams included Quality Improvement, Workforce and Organisational Development, Constitutional Standards and Financial Recovery. 

 

Quality Improvement Programme (Rating – Amber/Green)

 

An update on the main areas of concern where significant issues were:-

 

Safeguarding (Amber rating) – Additional safeguarding training had been established to provide sufficient capacity to deliver training to all relevant staff.  Compliance had significantly improved although some clinical areas had experienced difficulty in releasing staff to attend training due to site pressures and demands.  At the end of December 2015 compliance for Safeguarding Level 1 Core Learning was 80% against a trajectory of 95% by 31 March 2016.  Work was ongoing to explore the possibility of providing an e-learning package to complement face to face training.  The RAG [red, amber, green] rating had remained the same since the previous update in October 2015.

 

Hospital at Night (Green rating) – This model had been implemented to improve care to deteriorating patient during the night.  Focus was now on the implementation of the recommendations from Health Education for East Midlands (HEEM) and phase 2 of the project was being developed to maintain a focus on improving these services further.  The RAG rating had improved from Amber since the previous update in October 2015.

 

Control of Infection (Amber rating) – A full review of housekeeping, cleaning capability and capacity was commenced in December 2015.  When the findings of this review had been received, a business case would be developed.

 

A major outbreak of the norovirus was effectively managed during December and January with 199 symptomatic patients affecting 16 wards, 11 of which were closed during the peak.  The RAG rating had remained the same since the previous update in October 2015.

 

Training and Appraisal (Amber/Green rating) – It was reported that this project had now moved to the Workforce Improvement Programme and would be discussed within that section of the report.

 

Out-Patients (Amber/Green rating) – Environmental improvements had been made in Lincoln Out-Patient Department with Clinic Room standards being introduced to ensure that all areas were clean, tidy and equipped for use.  The booking system for follow-up patients had been improved and there was now a full understanding of the number of patients waiting for follow-up appointments with "time critical" patients clearly identified.  Work was ongoing to deal with the capacity shortfalls in order to provide sufficient appointments.  The RAG rating had remained the same since the previous update in October 2015.

 

It was reported that the Chief Executive was the chair of the Lincolnshire Wide Quality Improvement Programme Board, in addition to the internal ULHT Quality work, which was attended by all stakeholders and had a focus on Lincolnshire Wide Frailty Services, Safeguarding CAMHS, Adult Mental Health and Paediatric Commissioning.  The next meeting would begin to focus on 2016/17 priorities.

 

Workforce and Organisational Development (Amber/Red)

 

The programme scope outlined the development and implementation of projects to deliver the required improvements in workforce and staffing.  The milestone plan and work streams were revised in November 2015 and approved by the Improvement Board.  A Senior Programme Manager was appointed and the Workforce Programme Board met fortnightly with monthly reporting to the Improvement Board and Workforce & OD Committee. 

 

The focus for the revised work streams for the programme was:-

 

Nursing Workforce Utilisation (Amber/Red rating)– Monitor and the Trust Development Authority (TDA), in October 2015, launched a set of rules governing the use of agency staff which meant that any Trust subject to agency spending needed to secure agency staff via an approved framework agreement.  These rules also imposed an annual ceiling for total agency expenditure.  A dedicated team had also been established to undertake a bank service review to support delivery of the agency cap.

 

Progress had been made with changes affecting an expenditure reduction and had been achieved by utilising the workforce more effectively.  Key performance indicators had been developed to enable areas requiring improvement to be monitored.  Members of the Executive Team were also providing more focussed support and challenge to ensure pace be maintained and issues unblocked. 

 

Medical Workforce Utilisation (Amber/Red rating) – The agency cap, previously noted, was also applied to medical agency usage.  Progress had been made in relation to controls for agency usage and plans to ensure the existing workforce was used effectively.  Medical Teams were actively involved and had reduced overall expenditure by approximately £600k per annum following a reorganisation of medical rotas.

 

Recruitment and Retention (Amber rating) – A CQC Compliance Note was currently in place for Nurse Staffing Levels and monitoring systems were in place on wall wards with active recruitment taking place to reduce the vacancy rate.  There was local active engagement with the University and students and apprenticeships were now in place.  Open days were being held to attract school leavers.

 

Further recruitment was undertaken in January 2016, when a team travelled to Manila and successfully recruited 131 candidates.  These candidates were now being processed through the formal HR checks.  In addition, six registered nurses arrived in Boston from the European Union on 6^th February 2016.  More overseas recruitment drives were being planned.

 

A comprehensive marketing and communications plan was also being developed to retain the existing workforce. 

 

The RAG rating for these areas had changed from Amber/Red for Recruitment and Amber/Green for Retention to an overall rating of Amber since the update in October 2015.

 

Electronic Staff Record (ESR) (Amber rating) – This system was expected to improve central management and reporting of workforce details.  The ESR Supervisor Self Service was being rolled out across the organisation and would enable line managers to access real time information for all staff in respect of contract details, core learning compliance, annual leave and absence rates.  The RAG rating had remained the same since the previous update in October 2015.

 

Training and Appraisal (Amber/Green rating) – The Core Learning Compliance was reported as 78% and Appraisals at 67% at the end of December 2015.  The focus was to maintain and improve compliance over the winter period with a view to delivering 95% compliance by 31 March 2016.

 

Constitutional Standards (Amber)

 

The programme scope outlined the development and implementation of projects to deliver the required performance improvement against the constitutional standards as set out in the regional escalation system recovery letter and was consistent with the Lincolnshire wide recovery plan.  The scope and milestone plan were in place and a Programme Manager had been appointed to provide dedicated support for three months.  The programme provided a monthly progress report to the Improvement Board and SRG on risk and issues.

 

The programme had three major work streams and had an overall "Amber" RAG rating which had remained the same since the previous update in October 2015:-

 

Urgent Care – It was noted that performance within Pilgrim A&E Department continued to be a concern.  As a result, the Chief Operating Officer had appointed an additional Deputy Director to provide a dedicated focus on developing the future state for Pilgrim A&E.  Operational teams had been realigned to focus on daily improvement in flow and performance and key operational leads had been involved in developing a 30-day plan based upon high impact actions.

 

Length of Stay – The SAFER Bundle was being implemented, to support improvements in Length of Stay, and this was being supported through the "Perfect Week" initiative which commenced on 1^st February 2016 across the Lincolnshire system.   The SAFER bundle was a national initiative to improve patient flow by:-

 

S – Senior Review (Consultant review before midday)

A – All patients had an Estimated Date of Discharge (EDD)

F – Flow of Patients (wards to start to pull from Assessment Units by 10am)

E – Early Discharge (33% before midday)

R – Review (clinical review of patients with extended length of stay over 14 days)

 

Planned Care – All projects were progressing and this work stream closed and managed through normal management processes.  ULHT had achieved Referral to Treatment Time (RTT) performance for five consecutive months and eight out of nine Cancer standards during November 2015.  Risks remained, however, but were now actively managed.

 

Financial Recover (Amber/Red rating)

 

The financial recovery programme was progressing with a number of schemes now showing delivery against actual spend.  Schemes were being managed and governed with a clear programme structure to ensure the escalation of issues and risks were timely and resolved wherever possible.  The programme reported fortnightly to the Improvement Board.  Four main areas within the programme required significant focus:-

 

Nursing Workforce Utilisation – Progress had been made with actual changes effecting an expenditure reduction.  The Executive Team had provided some focussed support in the form of "deep dive" meetings which had ensured pace and unblocked a number of issues.

 

Medical Workforce Utilisation– Progress had been made in relation to the medical workforce although it was reported that there had not been an actual reduction in spend overall.  There had been a reduction in the price of agency doctors through renegotiation with the demand being reduced through the improvements made by clinical teams.  A £250k improvement in spend within integrated medicine by revising rotas and using doctors more efficiently was reported as an example of good practice.

 

Income – Progress was also being made in ensuring income was maximised by ensuring that the Trust received the best practice tariff.  It was explained that this was the tariff for delivering best practice care for the patient.

 

Tactical – An expenditure and income position (Control totals) for the end of this financial year had been agreed with all business units who were managing the delivery of this.  The Executive Team were providing additional support to areas where this was required.

 

Finally, in relation to governance arrangements, it was explained that the Portfolio Improvement Board was chaired by the Chief Executive with full executive attendance.  This was further supported by the Improvement Director of the Trust Development Authority (TDA) and a newly appointed Associate Director of Improvement.

 

Members were given the opportunity to ask questions during which the following points were noted:-

·       In 2015 140 nursing students had qualified from Lincoln University but only 60 had chosen to be employed by ULHT and, although the Trust would not expect the full cohort to stay in Lincolnshire, it was felt that 60 was too low.  So far this year out of 200 students, 118 had applied to the general advert with some appointed to specific wards, which had been a marked improvement;

·       As the numbers would still be insufficient, international recruitment had been undertaken.  During this recruitment, the Trust had been very honest with applicants about Lincolnshire and the nature of the county and the city of Lincoln itself to minimise the number of nurses taking jobs in Lincolnshire and then leaving for alternative locations;

·       Although the checks and balances were ongoing, some already had General Medical Council (GMC) registrations to be able to work in the UK and it was anticipated that some would be able to start work sooner as a result;

 

At this point of the proceedings, Councillor S L W Palmer asked that it be noted that he had an outstanding serious complaint with United Lincolnshire Hospitals NHS Trust.

 

·       Although safeguarding training was Amber rated this was due to acknowledgement by ULHT that further improvement was required.  There were opportunities for more online training which would reduce the time away from the wards.  Cascade training was suggested but this was not possible for safeguarding due to statutory obligations of this training.  The requirement was that this training be delivered by skilled and experienced trainers in this area;

·       Control of Infection was also Amber rated but it was anticipated that it would move to a Green rating soon.  The delay had been as a result of the recent norovirus but the Committee were assured that this area had made significant improvement;

·       Workforce issues were expected to take a number of years to resolve.  Although attrition rates had reduced to an average of 9.68% the Trust were looking to further reduce this and, if successful, the current situation would not worsen.  The reality for the next five to seven years was that ULHT would not have the required level of nurses and midwives.  Creative thinking about the roles of staff within the Trust was underway to ascertain how to utilise time and skills better;

 

At this point of the proceedings, Councillor P F Watson advised that she was a cancer patient receiving care from United Lincolnshire Hospitals NHS Trust.

 

·       Concern was raised regarding the process for a consultant declaring a patient medically fit to leave and it was asked whose responsibility it was to notify the GP about any future requirements of that patient.  ULHT were aware of this issue and work was ongoing to improve the situation.  It was explained that every outpatient appointment follow-up letter would be sent to the GP, usually within one week of the outpatient appointment.  A key piece of this work was to look to develop a single system for patient records;

·       The Committee challenged the appointment of a Consultant Nurse for Control of Infection and the cost involved.  The role had been created following a restructure of that team and utilising the money within that team.  The role was to give kudos to infection control to ensure compliance across the Trust;

·       There remained a number of vacancies for radiographers, midwives ad physiotherapists and the challenge was to make these roles attractive to professionals to attract them to Lincolnshire;

·       There were some services which required more resilience and help from other Trusts would be sought, but this would be a slow process as a mutual agreement benefiting both parties would have to be reached to be a longer term solution.  At present ULHT had a good relationship with University Hospitals of Leicester NHS Trust (UHL);

·       It was noted that performance was a concern rather than care and performance of teams.  In terms of timeliness, it was acknowledged that greater improvements were required but that these would be challenging and not resolved quickly.  The Committee were assured that lots of work was ongoing to improve performance and to make the workforce more resilient;

·       A lot of progress was reported within the system of complex discharges with the focus on having discharge hubs in place across all hospital sites.  It was confirmed that there were currently 70 people in beds across the Trust who were medically fit for discharge but needed a number of a requirements in place before they could be safely discharged.  As a result, work was ongoing as to how to better utilise community hospitals;

·       The report in relation to the review of housekeeping was expected within a few weeks, following the assessment of the norovirus.  It was confirmed that the Trust employed in-house cleaners who were now responsible to the Ward Sister.  The review looked at the cleaning schedule and the correct allocation at different times of the day.  During the winter, additional money had been allocated for cleaning due to the heavy footfall within A&E;

·       Although the NHS worked 7 days per week, it was acknowledged that staff were already providing 24/7 cover.  It was stressed, however, that elective care was not reliant on medical staff only and was a team effort, including porters and Health Care Assistant, for example.  The wider impact on the system had not been considered during these national debates and there were cost implications;

·       Clarification was given that the term 'junior doctors' did not only apply to newly qualified doctors but also applied to doctors up to a Consultant level;

·       Hospital capacity on the East Coast and in the south of Lincolnshire had implications for Delayed Transfers of Care due to the lack of capacity in community hospitals.  Despite the situation not worsening, it was acknowledged that significant improvements were still required;

·       Work had been undertaken to review nursing shift patterns and offer flexible working although this needed to be tailored to ensure care provision was at a sufficient level and robust.  These arrangements were reviewed on a six-monthly basis to ensure that any changes in personal circumstances were considered whilst ensuring full staff coverage.  Work was also ongoing with the internal nurse bank and also the provision of new technology which allowed staff to book bank shifts remotely;

 

At 12.48pm, Councillor R C Kirk left the meeting and did not return to the morning session.

 

·       Nurse demand had fundamentally changed over the years and this was the reason why the Nursing and Midwifery Council (NMC) had been more rigorous to ensure the profession remained respected, however there were restrictions in recruitment and training.  The Trust could develop its own nurse training programme but it would be at a huge cost.  The aim was to make ULHT attractive to school leavers;

·       Although ULHT worked in partnership with the University these restrictions were set nationally which made it difficult to look at new ways of working;

·       The 'agency cap' was the process whereby the Government sought to limit the price paid to agency and locum staff, so that ideally Trusts would work collectively to keep costs down, but patient safety remained the primary consideration.  Out of 241 Trusts it was reported that ULHT were in the worst five for breaching this cap therefore the focus must be on improving this situation as the Trust were under scrutiny;

·       Each request for an additional agency nurse was approved by the Director of Nursing and each request considered on merit balancing quality and safety of the patient;

·       A Sustainability and Transformation Plan was required for Lincolnshire as a result of the NHS Planning Guidance 2016/17 – 2020/21, to address the Five Year Forward View.  Without this and a clear way forward, the Trust could face administration but it was advised that this was some way in the future and only if improvements were not being made.  It was suggested that the Committee might wish to consider the Sustainability and Transformation Plan, prior to its final submission in June 2016.

 

The Chairman thanked officers for their frank and honest answers and looked forward to welcoming them to a future meeting for a further update.

 

RESOLVED

 

1.    That the report and comments be considered and a further update from the Trust be submitted to a forthcoming meeting; and

2.    That consideration be given to including Lincolnshire's Sustainability and Transformation Plan, prior to it submission in June 2016.

 

 

NOTE:       At this stage in the proceedings, the Committee adjourned for luncheon and, on return, the following Members and Officers were in attendance:-

 

Lincolnshire County Council

 

Councillors R C Kirk, S L W Palmer, Mrs S Ransome, Mrs J M Renshaw, T M Trollope-Bellew (Vice-Chairman) and C E D Mair

 

Lincolnshire District Councils

 

Councillors J Kirk (City of Lincoln Council), T Boston (North Kesteven District Council), C J T H Brewis (South Holland District Council (Chairman)), and Mrs R Kaberry-Brown (South Kesteven District Council)

 

Healthwatch Lincolnshire

 

Dr B Wookey

 

Also in attendance

 

Andrea Brown (Democratic Services Officer), Simon Evans (Health Scrutiny Officer), Sarah Fletcher (Chief Executive - Healthwatch Lincolnshire) and Chris Weston (Consultant in Public Health, Public Health Intelligence)