Ruislip Residents' Association

Dr Susan LaBrooy, Medical Director, The Hillingdon Hospitals NHS Foundation Trust, was guest speaker at the May 2012 meeting of The Community Voice, of which we are a member.  Dr LaBrooy had been assisting NHS North West London in its proposals for service reconfiguration, which she was pleased to do, as The Hillingdon Hospital had posed few problems in recent years, had consistently achieved financial balance, was on the periphery of the area - and its needs were thus easily forgotten.  Her participation had helped to bring attention to the needs of that hospital.

NHS North West London covers a relatively small area and has always delivered good services with low mortality rates. It aims to improve care even further, but the current financial constraints make this difficult, so improved services depend on new ways of working.  Changes are needed for many reasons. Patients admitted at weekends face higher mortality risks, because many hospital departments do not work 24 hours a day seven days a week. Recent advances have led to surgeons having greatly increased sub-specialisation, which provides very improved outcomes for patients, but requires large hospital teams serving extensive populations.

Local pioneering achievements are a source of pride  – Harefield Hospital’s angioplasty for heart attack patients, North West London’s very successful stroke service and improved vascular services.  All these successes depend on centralisation of enhanced services and require large catchment groups - both factors will be important in future service changes.

Improved out of hospital care had often been talked about and sometimes promised, but has not been achieved, but the speaker held high hopes that at last improvement is within sight, with funding to make it happen. This year the plan is to focus on the care of the elderly and diabetic patients, with liaison between mental health services, social services, acute and community services, all aiming to keep the patients in their own homes and out of hospital. Later this year the project will extend to patients with chronic heart problems.

Other initiatives in the local community were quoted. The 111 telephone service, currently being piloted in Hillingdon, provides telephone advice day and night for Hillingdon residents. GP networks provide enhanced services close to patients’ homes. A new Urgent Care Centre at Hillingdon Hospital will triage patients and improve services.

Performance

Only items of special interest items are noted, from a mass of performance data, January 2012.

Key:

E = Ealing Hospital NHS Trust;                 NWP = Northwick Park Hospital;                       NWL = NW London Hospitals;

THH = The Hillingdon Hospitals NHS FT;    RBH = Royal Brompton & Harefield NHS FT;       All = E + NWL+THH+RBH;

YTD = Year to date                                   Underline shows failed target

• Clinically unjustified breaches of single sex accommodation;                                       NWL=4;  rest =0
• 18 weeks target, referral to treatment for 90% admitted patients YTD:         E=88.6% rest on target
• Ditto for 95% of non-admitted patients: All on target, both in month and year to date
• 18 weeks admitted median wait 11.1 weeks: All on target
• Ditto, non-admitted 6.6 weeks:                                                    RBH=6.8    E=6.72       NWL=5.22   THH=4.05
• MRSA cases per 100,000 bed days YTD:                                      RBH=0       E=0           NWL= 2.72  THH=5.04

• Patients’ waiting for diagnostic tests >6 weeks YTD:                   RBH=0      E=577        NWL=42      THH=1

                                                                                                    but All=0 January

• Total time in A&E 95% < 4hours:                                                                    E=94.6%   NWL=89.2% THH=97.0%
• Unplanned re-attendance at A&E within 7 days <5%:                                    E=11%;     NWP=9%;    THH=8%
• A&E time to initial assessment 15 mins.:                                                       E=15:        NWP=88;     THH=7
• A&E time to treatment median 60mins.:                                                        E=48;        NWP=96;     THH=80
• LAS arrival to patient handover 85% 15mins, last quarter:                            E=84.6%   NPH=57.1     THH=71%
• Ditto 95% in 30mins:                                                                                      E=95.5%   NPH=91.2%  THH=95.3%

Shaping a Healthier Future:

Public consultation: Options for consultation on service changes will be considered by the Board at a meeting on 27^th June 2012. The start of formal public consultation is scheduled to start at the end of June. The consultation is expected to propose the closure of possibly three A&E Departments and centralisation of elective services in those hospitals, with enhanced A&E services at the remaining NW London sites, including Hillingdon and Northwick Park hospitals.  The proposals will be subject to approval by NHS London.

Stakeholder events: The third event is on Tuesday 15^th May, 6-9pm at the Sattavis Patidar Centre in Wembley (refreshments from 5.30pm).   Patients, public and clinicians can attend but must register in advance.

Other stakeholders: The programme has met every Overview and Scrutiny Committee in the area at least once and has met every provider of services and work is underway to engage with providers’ clinical staff. Newsletters have been sent to all GPs. There has been initial engagement with MPs and council leaders in constituencies likely to be most affected.

Transport: A Travel Advisory Group is being established

Primary Care Trusts

Interim arrangements: PCTs will cease to exist on 31^st March 2013. Until then accountability and statutory powers remain with the PCTs whilst their functions move to CCGs throughout 2012/13. The former Outer North West London Cluster Board was revoked, as in future the eight PCTs in NW London will meet in common, except when business dictates other arrangements. They will establish shadow CCG Boards as Committees of the PCTs and will have a single set of Non-Executive and Executive Directors to give maximum support to CCGs during their shadow year. The executive team will report direct to the NW London Chief Executive.

Clinical Commissioning Groups:

Composition: There are two Groups of four CCGs in NHS NW London.

• The Inner Group comprises: Central London (Kensington / Chelsea area);  Great West (Westminster area); Hammersmith and Fulham; and West London (Hounslow area).
• The Outer Group comprises: Brent; Ealing; Harrow; and Hillingdon

Officers: In May, each Group will appoint a shared Accountable Officer and Director of Finance.

Delegation of budgets: Only 4 of the 8 CCGs are recommended for delegation without conditions

• No conditions: Brent, Central London, Hammersmith & Fulham, and West London
• Must produce a financial recovery plan by 30^th June: Ealing, Harrow, Hillingdon, Great West

Commissioning Support Service: Both Groups have approved commitment to the CSS, which is a support service accountable to the CCGs as its commissioners, not an arm of the National Commissioning Boaard.

Authorisation process: CCGs applications will be considered in four waves in June, July, September, and October 2012. Outer NW London CCGs hope to apply in July or September. CCGs are not required to have identical constitutions.   Applications must include:

• Surveys from a range of stakeholders to confirm that the CCG is interacting with local people
• The CCG’s commissioning plans for each patient group, with focus on equality and diversity
• Up to five case studies showing how the CCG will support typical patients.

If not authorised by April 2013, the NHS Commissioning Board will either assume commissioning responsibility or ask another CCG to do so. Authorisation may include conditions.

CCG Board meetings in public: Meetings in public will begin in 2012/13

As part of the London 2012 bid the NHS has committed to providing business as usual throughout the Games (Olympics from 27^th July to 12^th August. Paralympics from 29^th August to 9^thSeptember). Other parts of the NHS will provide health services for both athletes and visitors, so what will impact on NW London services?

The Olympic and Paralympic Route Networks: These are roads designed for the rapid transfer of “Games Family” members (athletes, officials, the media and sponsors). Around a third will contain Games Lanes, closed to non Games Family Members. A number of restrictions will be in place including banned right turns, changes to traffic signals, parking and pedestrian crossings.

Torch Relay: The Torch Relay will pass through the NW London Cluster’s area from 24^th – 26^th July with a rolling road closure with spectators along the route. The Torch passes directly in front of Hillingdon and Ealing hospitals, which have plans to prepare for the impact.

NHS plans: Plans are in place to advise patients of the impact on their visits to NHS sites. NHS London and TfL are liaising to ensure that patient transport vehicles can access Games Lanes where patient care is at risk. Policies are in place to ensure that annual leave does not disrupt usual service delivery. The LAS has secured additional funding from the DH to support its service.

Overperformance: Whilst there have been more hospital activities than in the plan for this point in the year, London has had much more controlled activity in 2011/12 than in previous years – it is no longer in an outlying position compared to the rest of the country.

MRSA: By end of February, London had exceeded its target for the year, but its 100 cases of MRSA showed an improvement since last year, when there were 140 cases by the end of January.  Next year will be even more challenging, when the target for London is reduced from 99 cases to 74.

Health checks: Only 11.66% of the eligible population in London had been offered health checks to the of Quarter 3, below the plan of 13.18%.  Both NHS Harrow and NHS Hillingdon were below their targets.

Health Visitors: NHS London continues to give health visiting a high priority but in November 2011 it had only 1109 health visitors against its target for 2011/12  of 1084.

Finance: There has been a significant improvement in the overall London position since month 8, despite activity levels being higher than planned and a continued shortfall in expected savings. Transitional support for London providers who are unable to fully recover the cost of complex procedures through the national tariff has helped the overall position, as this support was not in trust plans.  At month 10, the overall forecast position for London was a surplus of £281.5m.

London’s Harm Free Care Pilot:

Harm Free Care is a two year programme, started in January 2011, that involves ten London trusts.  It is based on improving patient experience by minimising the four avoidable harms listed below – it achieved an improvement of 6.6% amongst surveyed London patients up to September 2011.

• Pressure ulcers
• Falls
• Catheter acquired urinary tract infections
• Venous thrombo-embolisms

The target is for 95% of patients in London to receive harm free NHS care.  If achieved, this would benefit 73,675 people!

In 2012 the programme will have four strands:

• Reduction of the four main avoidable harms in Mental Health Trusts – violence and aggression; falls; self harm and medication errors
• Reduction of harms in Care Homes
• Deeper and wider spread in the ten 2011 pilot acute trust sites

London Health Improvement Board: This Board met for the first time late in 2011 under the Mayor’s chairmanship and set four priorities:  childhood obesity; early diagnosis of cancer; alcohol abuse; and the provision of better information for patients.  In answer to questions at the end of the meeting of NHS London Board in January 2012, it was noted that when NHS London is abolished, on 31^st March 2013, this may be the only body  taking a strategic view of NHS services pan-London – but the NHS Commissioning Board may possibly initiate something of this kind. Subject to the Bill becoming law, both SHAs and PCTs will be abolished on the above date.

Finances: Five London Trusts have planned deficits, including North West London Hospitals Trust, plus one reporting an unplanned deficit.

 Hospital Trust performance: At week ending 1^st January four Trusts failed to reach the 95% target for treatment in A&E within four hours – including North West London Hospitals Trust, which was also among the eight Trusts not delivering the 95^th percentile for admitted waits within 18 weeks as well as breaching its maximum MRSA trajectory with 5 cases (target maximum 3) and its clostridium difficile target.  Hillingdon FT also breached its MRSA target with 4 cases (target 3) but it is appealing this breach as a single complex patient has now been counted for six MRSA episodes!

The Challenged Trust  Board has been abolished: In future NHS organisations in London in financial difficulties will look to the Delivery Group and the Capital Investment Committee for assistance.

Emerging Clinical Commissioning Groups in London

Applications for authorisation by the NHS Commissioning Board will be received from July 2012.  The proposed authorisation process is built around six ‘domains’.

• A strong clinical and multi-professional focus which brings real added value.
• Meaningful engagement with patients, carers and their communities
• Clear and credible plans – including meeting QIPP(quality, innovation, productivity and prevention) challenge within financial resources, plus excellent outcomes and local joint health and wellbeing strategies.
• Proper constitutional and governance arrangements
• Collaborative arrangements for commissioning
• Great leaders who individually / collectively can make a real difference

There are three potential outcomes of Authorisation

• Fully Authorised:  CCGs commission all relevant services for their population.
• Authorised with conditions: This means not fully authorised – the CCG may not be ready  to take on the full range of responsibilities.
• Shadow CCGs:  CCGs statutorily  established but  either unwilling or not ready to take on any commissioning,  The NHS Commissioning Board will ensure all functions are undertaken for their populations.

Shadow budget allocations for emerging CCGs will be published early in 2012 for those CCGs assessed as ‘green’ or ‘amber’, which includes all 32 of London’s CCGs.  Both Harrow and Hillingdon CCGs are rated green.  ‘Shadow CCGs’ will begin operating from April 2012, although they will still be accountable to PCT clusters.  This will allow them to build relationships, develop a track record and commissioning skills.  30 of London’s 32 CCGs are co-terminous with local authority boundaries, including both Harrow and Hillingdon CCGs.

£100m has been made available across the NHS in England to allow CCGs to support improving and sustaining performance on winter access to services – access to A&E and access to treatment within target times.  London’s share is £16m for this financial year and it being distributed by a bidding process for projects to improve access.  An additional £50m has been allocated to each SHA cluster for the same purpose ahead.

NHS London Board Meeting, October 2011.

Whistle blowing policy: The proposed policy states that its aim is to enable and encourage staff to report any malpractice, illegal acts, or omissions by employees, ex-employees or other NHS organisations in London.  It notes that staff may have doubts about raising concerns, think matters are not their business, that there is no proof, or that reporting may cause concerns about disloyalty – but that the policy has been introduced to enable staff to raise concerns immediately, confidentially, and with the assurance that these will be dealt with properly, with the caveat, “Please do not wait for proof of your concerns”.

Performance items: North West London Hospitals was one of the four London organisations below the 95% threshold for year-to-date type 1 A&E services.

Ealing Hospital was one of seven London trusts not meeting the target of 90% of admitted patients being treated within 18 weeks of referral and both Ealing and NW London trusts failed the 95^thpercentile target for admitted patients.  Ealing also failed the target for patients waiting more than six weeks for diagnostic tests.

NW London Hospitals and Hillingdon Hospitals featured among the seven London providers failing the 62 weeks cancer waits standard, between screening centre referral and treatment –

Both NW London and Royal Brompton were among the ten London providers failing the 62 weeks standard between urgent GP referral and treatment.

Infections:  London has seen less MRSA bacteraemias this year than in the same period last year.  NW London has breached its maximum target- but it has had only four cases, against its target of 3 for the whole year.

Activity levels: Activity levels in some parts of London are significantly higher than planned.  Trusts are also experiencing difficulty in delivering the level of cost improvement factored into their plans, which exceed even the unprecedented levels of savings achieved in 2010/11.

A&E concerns: National evidence shows that patients admitted as an emergency at weekends have a significantly greater chance of dying than patients admitted during the week – this variation in mortality rates exists across the capital.  Reduced services provision at weekends is associated with this higher mortality rate.  Pressures include reduced working hours for junior doctors, a reduction in training numbers across London increasing the need for consultant-delivered care, and increasing pressures due to sub-specialisation – fewer consultant general surgeons will be able to staff emergency rotas over the next 3 to 5 years.

Provisional data also suggests that where systems are in place to respond seven days a week, there is a beneficial effect on mortality rates.  Since the development of London’s Hyper Acute Stroke Units the disparity between weekend and weekday mortality rates in stroke patients is reducing and is expected to reduce further so that in London there is no longer any significant differences in mortality rates for stroke patients whether admitted at the weekend or on a weekday.

London Review of Maternal deaths: During the period under review, the first six months of 2010, the London Maternal Death rate was 19.3 / 100k maternities compared to the national rate of 8.6 / 200k maternities. 66% of women who died were from Black and Minority ethnic groups.  52% were from the lowest two quintiles of the scale of deprivation.  Body mass index was a significant factor with 50% of the women either in the overweight or underweight category.  26 of the 34 deaths reviewed had avoidable factors identified and aspects of care were said to be poor in approximately 50% of the cases.