Decision details

The Barts Health NHS Trust chief executive explained that an inspection of Whipps Cross hospital by the Care Quality Commission (CQC) had taken place in November 2014 and had revealed significant concerns in a number of areas including A&E patient flow, staffing and bullying. Following the inspection, a risk summit was organised with stakeholders in March 2015 and Barts Health wished to be inclusive with other organisations as part of its improvement plan.

Significant concerns raised by the CQC included issues of staffing, morale & culture, the routine delivery of standards such as keeping to timetables for treatment and the lack of safety policies and embedding of safety etc. The Trust management believed that the public would still get good outcomes and care at Whipps Cross but accepted that patients had been let down. While there were good aspects of care at Whipps Cross, improvements were also required.

The Trust Medical Director explained that immediate recovery action was agreed with the Trust Development Agency, local Clinical Commissioning Group (CCGs) and Healthwatch Waltham Forest.  Significant progress had been made around improving the quality and safety of clinical care. Daily meetings were held where nurses could share any concerns around patient care. The number of medical patients treated on surgical wards had been reduced and the seven-day site presence of senior management had also been improved.

As regards staffing levels, improvements had been made but there was still a reliance on use of agency staff on some wards. The budgeting process for the nursing establishment was currently in progress and the Trust aimed to reduce its need for agency staff. On safeguarding, the introduction of a babytracking system at Whipps Cross maternity had not been concluded and the Trust accepted that this needed to be actioned. Recruitment had taken place to the senior leadership team whose visibility had improved, making it easier for staff to escalate issues if necessary.

The Trust and hospital leadership were keen that staff understood and engaged with the hospital improvement plan. On outpatient issues, the Trust wished to meet waiting time targets, avoid duplication of appointment letters and ensure patient records were available at appointments. In A & E, the objectives were to ensure patients were seen and assessed promptly, admitted to the correct ward and discharged safely.

Trust officers felt that recruitment had improved with the ratio of permanent, agency and bank staff being looked at. A new eight-bed High Dependency Unit was due to open was due to open at Whipps Cross by December. It was accepted that communication around the hospital improvement plan had to be improved both with stakeholders and the general public and also with the hospital’s own staff.

It was also important that staff were engaged in delivering better care and a clinical senate had been established to manage the hospital at a local level. A quality and safety committee would also be set up to allow safety issues and complaints to be dealt with on site at Whipps Cross.

The final area of the hospital improvement plan covered compassion in care – an area of good practice referenced in the CQC report. A compassion in practice working group dealt with key areas of concern such as care of the elderly and dementia. It was aimed to make the hospital estate more dementia friendly.  End of life care – an area criticised in the CQC report was also being worked on. Work was being undertaken with the Patients Association and the hospital was keen to work with both local and national patient groups.

Questions and discussion

The Trust chief executive agreed that the raising of concerns by staff should be encouraged and felt that it was people’s duty to do this. Staff would not be penalised for raising concerns and the Trust had a private means for staff to raise concerns about issues such as bullying. This had been reinforced in the values of the organisation and 1,500 staff leaders were being trained in the Trust’s values.

The hospital areas with the highest amount of reliance on agency staff were children’s in-patients wards, surgical wards and A & E. Whipps Cross now had a full complement of ED consultants but struggled to recruit ED nurses. The recruitment situation on the children’s wards had improved recently although there remained large numbers of new staff in this area.

The new leadership at Whipps Cross did have the authority to tackle problems at the hospital. The post of managing director at the hospital was currently on an interim basis but would be advertised permanently in due course. This would allow a higher level voice to represent Whipps Cross to the Trust Board.

Recruitment in paediatrics was a national issue. Specialist recruitment agencies and incentive packages were therefore employed to aid recruitment to these areas at Whipps Cross. It was hoped to reach almost full establishment for children’s staffing at Whipps Cross by the end of March. Elderly wards were now almost at full establishment and the new staff were of high calibre and enjoying working at Whipps Cross. Recruitment difficulties for surgical wards were also seen in other areas rather than just Whipps Cross. The Trust wished to use their own staff bank to fill vacancies rather than external temporary staff. Other incentives to attract staff being considered included rotation across sites, clear career pathways and education & training opportunities.

The private finance initiative (PFI) did not impact on the quality of care at Whipps Cross. The PFI cost did total £28-30 million and the Trust wished to address the long-term issues around this. The estate at Barts and the Royal London hospitals was in a good condition. The remainder of the Trust’s estate required an upgrade however and there was a maintenance backlog across the Trust of approximately £80 million. Around £16 million had been invested in the estate in 2014/15 although much of this investment was not visible to the public. The four oldest operating theatres at Whipps Cross were being replaced at a cost of £9.2 million.

The communications strategy around Whipps Cross would include the local press and local residents. The Trust wished to improve patients’ experiences and then make these improvements clear to the wider public. It was suggested that the annual Barts Health awards could be hosted at a venue closer to Whipps Cross in order to boost the profile of the hospital.

Hospital management accepted that most media stories about Whipps Cross (both positive and negative) were true but there were also some areas of very good practice at the hospital. These included endoscopy and the new heart service at the hospital. The induction of labour had been improved at Whipps Cross maternity and this had been praised in the CQC report.

The Trust respected equal pay obligations and the requirements of safe staffing. London weighting issues were also taken into account. As regards falls prevention and frailty of patients, the Trust was prioritising this and wished to adopt national best practice on frailty. More senior geriatricians needed to be employed by the Trust and more weekend working would be introduced in order to develop the elderly pathway. A falls strategy had been operating at the Trust for the last two years and all wards were required to report incidents of patient falls. The number of falls across the Trust as a whole had been reduced but further improvement was needed.

The Trust wished to extend the opening hours of its Patient Advice and Liaison Service (PALS) in order that the service was available out of hours. Recruitment to a more dynamic PALS model was currently under way.

As regards end of life care, a compassionate care plan for the dying had been produced but its implementation had been delayed. Staff training on this policy was expected to start shortly. It was accepted that more work needed to be done at the Trust on end of life care. The Trust was not aware of any issues around screening programmes being raised by the CQC.

The Trust chief executive felt that Barts Health did have a fully committed and dynamic management team. A new Trust Chairman was due to be appointed in early June and further senior appointments would follow.

A lot of partnership working was included in the improvement plan and the overall nursing strategy and care model. Regular use was made of national networks such as the Health Education Network. The robustness of patient panels at Barts Health needed to improve and the Trust also wished panels to be more representative of their local communities with e.g. better youth representation. The Trust had obtained funding in order to develop this work.

Further details would be supplied of the Trust’s work with people with dementia. A Member felt that the needs of people with dementia should be considered in all areas of the hospital and had established that this had not been done in the design of the new heart hospital at Barts. It was noted that there was a Trust-wide dementia strategy group in operation.

It was AGREED that progress at Whipps Cross be considered again by the Joint Committee in approximately six months and that in the meantime, a site visit should be arranged for Members in order to gain more of an understanding of the challenges and issues facing the hospital. The outcomes of the current Waltham Forest scrutiny review of end of life care would also be shared with the Joint Committee.

It was further AGREED that it be established with the Joint Health Overview and Scrutiny Committee for Inner North East London what scrutiny that committee was undertaking of the issues at Whipps Cross. It was noted that scrutiny of the Whipps Cross improvement plan was already being conducted by Waltham Forest, Redbridge and Essex health scrutiny committees. Any relevant outcomes from this work could also be brought back to the Joint Committee.