Local Health Accountability Conference

Minutes of the Meeting held on 22nd January 2010

Commenced: 2.00pm
Terminated: 5.00pm

Present:

Dame Pauline Fielding (Chair)

Tameside Council Personal and Health Services Scrutiny Panel - Councillors Richard Ambler, Helen Bowden, Dorothy Cartwright, Walter Downs, Eileen Shorrock and David Sweeton.

Tameside Local Involvement Network - Bill Burgoine and Hanif Malik.

Tameside Hospital NHS Foundation Trust - Christine Green (Chief Executive), Philip Dylak (Director of Nursing), Rev. Tim Presswood (Chair, Trust Board), Stephen Gardner (Director, Planning and Performance), and Dr Tariq Mahmood (Medical Director).

NHS Tameside and Glossop – Dr. Tim Riley (Chief Executive), Dr Kailash Chand (Chair, Trust Board), Tom Wilson (Director, Contracting and Performance).

David Heyes (MP); James Purnell (MP); Rod McCord (Tameside Hospital Action Group); Angela Brown (North West Strategic Health Authority); Jack Meredith (Chair, Care Homes Association of Tameside) and Dr Alan Dow (Secretary, West Pennine Local Medical Committee).

Apologies for absence:

Councillors Jim Middleton, Bill Harrison and Jean Brazil (Scrutiny Panel), Dr Cropper (Scrutiny Panel co-opted member), Dr John Everett (Interim Medical Director, NHS Tameside and Glossop) and Andrew Gwynne (MP).

The Chair, Dame Pauline Fielding, welcomed the attendees and members of the public to the meeting and expressed her gratitude for the opportunity to once again engage with health services in Tameside, following her independent review of services for elderly people at Tameside General Hospital in 2008. 

The Chair highlighted that the purpose of holding the Local Health Accountability Conference was to provide an opportunity for members of the Scrutiny Panel, the Tameside Local Involvement Network (LINk), and other interested parties, to discuss with representatives of the Tameside Hospital NHS Foundation Trust the underlying reasons for the organisation’s performance, particularly in relation to the causes of high mortality rates and how the Trust intended to address the issues raised in the Dr Foster Quality Account 2009. It also provided an opportunity to engage with NHS Tameside and Glossop, as commissioner of services, regarding how they intended to work with the Foundation Trust in order to contribute to the improvement of performance both of the hospital and the local health economy.

Both the Foundation Trust and NHS Tameside and Glossop would deliver presentations and then respond to pre-submitted questions, copies of which had been provided for all attendees and members of the public. One supplementary query would be permitted following each question, in order to gain clarification of the information provided.

Tameside Hospital NHS Foundation Trust

Representatives from the Foundation Trust informed the meeting that the Dr Foster organisation calculated how many deaths each hospital would be expected to have, each year, given the conditions that patients were admitted with. The model took into account variables that could affect the death rate, such as the level of deprivation in an area, the age and sex of each patient, and the complications the patient may have had. The Dr Foster organisation then compared the actual number of deaths with the expected number. Previously the Foundation Trust focused on improving clinical services and staffing levels to reduce the mortality rate, however, the Trust were now also looking at addressing the “expected” number of deaths by improving the accuracy of primary diagnosis and recording the contribution of other illnesses.

Mortality rates at Tameside Hospital were slowly reducing. The raw mortality rate had consistently declined, from 9.4% (2004/5) to 7.3% (2008/9). The Dr Foster hospital standardised mortality rate (HSMR) had declined from a rate of 152 (2004/5) to 119 (2008/9). The mortality rate from elective admissions to the hospital was 91.3. However, there was still a consistent performance gap between the mortality rate at the Foundation Trust and the North West Strategic Health Authority average.

A range of Trust Board and operational level initiatives had been implemented to reduce mortality rates. The Foundation Trust Board had undertaken a Mortality Review in collaboration with the PCT’s Public Health department (2004); participated in an NHS Modernisation Agency Mortality Reduction Initiative (2005); entered into contract with the Dr Foster organisation to understand mortality rates (2006); established a Clinical Audit and Effectiveness Committee to better understand data on mortality (2007); implemented a Dignity in Care Plan (2007); accepted the recommendations of the Scrutiny Panel review on mortality rates (2007); and developed the Foundation Trust’s first Quality Account which focused on improving mortality. In addition, the Board routinely performance managed all operational activities in the hospital.

The Foundation Trust had introduced a range of operational measures to reduce mortality rates: -

• There had been a 55% increase in consultants since 2006/7. Between 2003 -2008, the doctor-bed ratio had increased from 30.4 per 100 beds, to 61.2 per 100 beds, and the nurse-bed ratio had increased from 119.2 per 100 beds to 178.2 per 100 beds.
• The Foundation Trust were working with partners to improve end of life care and this was recognised in Dignity in Care Plans. The Liverpool End of Life Care Pathway was implemented in 2006; and the Trust were exploring how to reduce inappropriate admissions of patients who were dying.
• In 2009 an extra intensive care bed was provided and the Critical Care Outreach Team was extended to provide a 24 hour service, to improve care for critically ill patients.
• A variety of clinical services had been enhanced, resulting in declining MRSA and C Difficile infection rates. The organisation was one of five Trusts nationally to achieve the highest accreditation for both general and maternity services.

From 2010 onwards the Foundation Trust would focus on improving hospital mortality rates by making improvements to clinical services. ‘Care bundles’ would be introduced for nine conditions, including hip fractures; the Trust would be working with external experts to improve services; senior consultants would review deaths on a weekly basis; the Trust would work with eight North West hospitals to improve mortality rates; a ‘Right Patient, Right Bed’ policy would be introduced to ensure patients received the care they required; and the Trust would undertake a retrospective case note audit for 2009/10.

In 2010, the Foundation Trust would also undertake a review to better understand the impact that accurate coding of clinical diagnoses and co-morbidities had upon the hospital standardised mortality rate. All deaths for 2009/10 would be re-coded and submitted to the Dr Foster organisation for re-calculation. The revised data for quarter one showed a decline in the mortality rate from 107.3 to 100.7.

Tameside and Bolton Hospitals both had both the highest proportion of emergency work and the highest mortality ratios of all Trusts in Greater Manchester. The Trust would be examining this possible trend.

The Foundation Trust was committed to improving the quality of clinical services and would use all available information to help achieve this.

NHS Tameside and Glossop (PCT)

Representatives from NHS Tameside and Glossop informed the meeting that, as the primary care trust (PCT) for the area, this organisation was the leader of the local NHS. The PCT’s role was to allocate resources to improve the health of the local population and reduce health inequalities by commissioning services and providing community centred services.

The PCT identified the health needs of the population, and using this information, commissioned services from a range of registered providers including hospitals, GPs, pharmacists and dentists. The PCT agreed contracts with each provider and monitored those contracts to ensure the services requested were delivered. The PCT also delivered community based services, such as district nursing and health visiting. In addition, the organisation worked closely with Tameside Council regarding social services and Tameside Hospital Foundation Trust in relation to hospital admission and discharge.

The PCT’s budget for 2009-10 was £409 million, and of this, £111 million was spent on commissioning services from the Foundation Trust. In the last two years, the funding for the hospital had increased by 17% (£16 million).

The NHS ‘quality system’ ensured that the services PCTs commissioned from providers were of good quality. This involved four levels: -

• Level 1: the providers of NHS services, such as Tameside Hospital, were responsible for monitoring the quality of services they delivered to ensure they were safe.
• Level 2: the PCT undertook formal contact monitoring of the services commissioned from each provider, using performance indicators and a range of other data including patient complaints.
• Level 3: Strategic Health Authorities held PCTs to account to ensure they monitored contracts with providers and Monitor held Foundation Trusts to account for adhering to their terms of authorisation.
• Level 4: the Care Quality Commission carried out inspections of hospital trusts and required them to submit self-assessments. The Department of Health ensured that systems were in place to ensure any risks and concerns regarding the delivery of care emerged.

Under the ‘Commissioning for Quality and Innovation’ programme, the PCT paid the Foundation Trust for delivering extra improvements to dignity in care services that were beyond the standard NHS requirements. In the last two years, the PCT had paid the Foundation Trust £600,000 for achieving ‘stretch targets’, in relation to reducing mortality, fractured hips, pressure ulcers and other areas of care.

In addition, the Foundation Trust and the PCT agreed key performance indicators for the hospital to achieve which encouraged continual improvement. There were no financial incentives for reaching these targets, however, the hospital could be could be fined for failing to meet them or implement plans to improve quality.

The PCT was working with the Foundation Trust to improve information sharing between the two organisations and provide greater assurance of quality. The organisation already had positive relationships with the Care Quality Commission and Monitor, as the regulators for NHS Foundation Trusts.

The Chair thanked the Foundation Trust and the PCT for their presentations and informed the meeting that pre-submitted questions would now be put to both organisations, copies of which had been provided for all attendees and members of the public. One supplementary question could be asked, for each original question, in order to gain clarification.

Questions and Answer Session

The following questions were put to representatives of the Foundation Trust: -

1.

1. What actions were being taken in April 2007 to reduce the hospital mortality rate and why is it that, more than two years later, those actions have failed to bring about a discernable improvement? (MPs)
   
   The Foundation Trust had steadily improved clinical services and mortality rates since April 2007. The organisation was currently undertaking a review of deaths at the hospital in order to more accurately record co-morbidities. It was likely that this review would result in a reduction in the mortality rate.
    
2. Why should the people of Tameside have any more confidence in the ability of hospital management to bring about real and sustained improvement in 2010 given their failure to deliver on the promises made in 2007? (MPs)
   
   Patient satisfaction was measured in a number of ways. Feedback from the ‘Patient Opinion’ website showed that many patients were happy with the services they received.
   
   The Dr Foster organisation measured each hospital trust’s performance against 39 indicators. The Foundation Trust performed within the expected range against 34 indicators.
   
   Supplementary question:
   What increase in budget has the Foundation Trust received in the last 2 years? (MPs)
   
   In the last 4 years the Foundation Trust had received funding only in relation to the number of patients treated and the complexity of their care.
    

2.

1. How long has the Standardised Mortality Ratio at Tameside Hospital been above average? (West Pennine Local Medical Committee)
   
   The hospital mortality ratio had been above average since elderly people’s services had been merged with the hospital.
    
2. For how long has the Foundation Trust known it was above average? (West Pennine Local Medical Committee)
   
   The Foundation Trust had been using the Dr Foster organisation to calculate the hospital mortality rate since 2006. Before this date, the organisation used a different provider to calculate this data. The mortality rate was decreasing and the Trust had undertaken all the actions it could to reduce it further.
    
3. Why does the Foundation Trust think this is the case? (West Pennine Local Medical Committee)
   
   The Foundation Trust partially understood the reasons for the high hospital mortality rate and hoped to reduce it to a rate of between 110 – 107, following re-coding of all patients deaths for 2008-2009.
   
   The organisation would be working with other hospital trusts in the North West that also had high mortality ratios to examine why the death rate was high.

3. Is the number of vulnerable elderly people being admitted, cared for and re-admitted to Tameside Hospital contributing to the high mortality rates and re-admission rates indicated by the Dr. Foster report? (Care Homes Association of Tameside)

The Dr Foster model attempted to standardise for variables in the population that could affect mortality rates, such as deprivation, age and general health. In comparison to Tameside, Trafford also had a large elderly population, however Trafford General Hospital had a significantly better hospital standardised mortality rate (81.62) than Tameside General Hospital. This suggested that factors other than age contributed to the mortality rate. 
 

4. Question for Christine Green, Chief Executive: Please elaborate on how deprivation and poor general health contribute to the high hospital standardised mortality ratio. (Tameside Hospital Action Group)

The Dr Foster model attempted to account for variables in the population that could affect the hospital standardised mortality ratio, such as social deprivation.

Often patients were admitted to the hospital with one condition, but also had other complex health problems. Each condition was assessed and treated. It was important that the Foundation Trust submitted accurate information to the Dr Foster organisation to ensure that all multiple health conditions, or co-morbidities, were recorded, as they could affect the hospital standardised mortality ratio.

6. Question for Tim Presswood, Trust Chair: Please explain the process by which you were able, so conclusively, at the Trust members’ public meeting in Stalybridge on 11th November 2009, to eliminate the standard of clinical services as a pertinent factor in the hospital’s high standardised mortality ratio? (Tameside Hospital Action Group)

The Chair apologised for creating this impression and clarified that clinical services were a factor, with many others, that affected hospital standardised mortality ratios. The Trust had improved clinical services and would continue to do so.

Mr McCord referred in detail to an elderly lady whom he had visited at the hospital a week before this conference. She had been in a separate room, in a distressed state, unable to access fluids and in unclean conditions.

The Foundation Trust was disappointed to hear about any poor patient experiences at the hospital.

Supplementary question:
Staffing levels on high dependency wards at Tameside Hospital appear to be deficient and may affect patient care. Why was the staff-to-patient ratio at Salford Royal Hospital higher than the staff-to-patient ratio at Tameside General? (Tameside Hospital Action Group)

Salford Royal Hospital provided more specialist services than those delivered at Tameside Hospital, which attracted higher tariffs, and enabled them to employ more staff. The Foundation Trust would like more staff, but had to work within existing resources.

5. Do you feel that it is still the case (that more seriously ill people are admitted to the hospital causing higher hospital mortality ratios) and what evidence do you have to support this view? (Tameside LINk)

The Foundation Trust admitted a high number of elderly patients between the ages of 80-89 years old. Some of these patients appeared to die from low risk conditions, however, upon further investigation it could be determined that they had other higher risk health problems. The Trust were working with the PCT to find more appropriate places for older people to be treated at the end of their lives.

8. What are the reasons for the apparent poor performance against the measures in relation to orthopaedic services, for example:

1. The death rate for patients with a broken hip (132.50)
2. The rate of unplanned readmissions for patients with a broken hip (155.59)
3. The rate of patients who have a hip replacement revised (2.87)
   (Scrutiny Panel)

The numbers of patients involved in the performance indicators relating to orthopaedic services were small.

For the current year, the death rate for patients admitted with a broken hip was within the expected range.

Patients that were re-admitted to hospital could return for a range of reasons that were not related to their orthopaedic treatment.

The rate of patients having a hip replacement revised was elevated, but within the expected range. An audit of orthopaedic services was currently taking place to examine the reasons for this.

12. The Scrutiny Panel have been informed previously about improvements to nursing care.

1. Have these improvements in nursing care been sustained? (Scrutiny Panel)
   
   The Foundation Trust had made changes to nursing care as a result of implementing the Dignity in Care Plan and regularly monitored progress with a range of measures, including nutrition, hydration and infection control. There had been sustained reductions in infection rates and pressure sores as a result. However, the Trust faced challenges sustaining these improvements due to higher winter workloads.
    
2. How do the newly appointed members of staff, for example the Infection Nurse and Modern Matrons, improve quality of services? (Scrutiny Panel)
   
   The Foundation Trust had implemented a system of ‘Matrons’ Rounds’, where they audited their own ward and one other ward on a monthly basis to ensure consistent standards across the hospital.
    
3. How does the Trust ensure that during staff handover, the appropriate information is shared between day and night shifts? (Scrutiny Panel)
   
   Formal handovers took place at the end of each shift and which required staff to update patient notes. This would be improved in the future as better technology becomes available.
    
4. Are new members of staff, including bank and agency staff, fully trained and shadowed to ensure the standards of care they offer are appropriate? (Scrutiny Panel)
   
   Last year the Foundation Trust began to use NHS Professionals (NHSP) to provide temporary staff. NHSP performed background checks on all their staff and provided training to ensure their staff met national standards. Demonstrating appropriate English language skills was a condition of registration for nurses. However, the Trust tried to avoid using agency staff where possible.

14. Dr Foster reports that 6% of day case patients end up staying longer (ie. overnight) for treatment at Tameside Hospital than expected. What are the reasons for this? (Scrutiny Panel)

It was preferable to treat day cases in one day. However, it was finely balanced medical judgement as to whether patients should be admitted for a longer period of time than anticipated.

16. How has the hospital analysed feedback from the Patient Advice and Liaison Service, official complaints or other feedback mechanisms, and what steps has it taken to make improvements based on it? (Tameside LINk)

The Chief Executive and Director of Nursing saw each complaint that was received about the hospital. The Foundation Trust also received other complaints information from a range of sources, including the Patient Advice and Liaison Service. An action plan was developed for each significant complaint and trends in complaints were reported to the Trust Board.

18. Will the hospital make a commitment today to working in partnership with the Tameside LINk, contributing to joint discussions where our members can help to shape improvement plans for the hospital’s services? (Tameside LINk)

The Foundation Trust was happy to work in partnership with the Tameside LINk.

The following questions were put to representatives of the PCT: -

19.

1. The Scrutiny Panel’s 2007 review of the hospital’s high mortality ratio suggested many people were admitted that were close to the end of their lives and died in hospital within a week. It was suggested this elevated the mortality ratio. As the commissioner of the hospital’s services, what steps have you taken to check whether this is still the case? (Tameside LINk)
   
   The PCT compared the hospital standardised mortality ratio for Tameside with other data including the actual number of deaths and the number of people who die at home. On average, 19.5% of people died at home, compared to 18.5% in Tameside Hospital. This was not a significant difference.
    
2. If you have had concerns about mortality ratios since 2007, what steps have you taken to help the hospital to improve its performance? (Tameside LINk)
   
   The hospital standardised mortality ratio for Tameside General Hospital had been decreasing for the past 5 years. Other hospital trusts in the area had not been able to sustain similar reductions.

20. Mortality Ratios and Dr Foster’s “How Safe is Your Hospital?” report are only two indicators of how well a hospital is looking after its patients.

1. What other performance measurement systems have you used, as the hospital’s commissioner, to assess patient safety and unexpected deaths? (Tameside LINk and Scrutiny Panel)
    
2. What have these performance measurement systems told you about the hospital’s performance in terms of patient safety and unexpected deaths? (Tameside LINk and Scrutiny Panel)
    
3. If these systems have raised any concerns, what steps have you taken to help the hospital to improve its performance? (Tameside LINk and Scrutiny Panel)
   
   The PCT assessed the performance of the hospital using clinical governance systems; by holding regular meetings between the Chief Executives and Chairs of both organisations; and through the Clinical Quality Review Group which examined specific areas of clinical quality. The PCT also agreed ‘stretch targets’ with the Foundation Trust whereby they were paid extra for delivering improvements that were above standard NHS requirements.
   
   The PCT were planning to improve how the patient’s voice was heard and would like to develop methods for the public to become involved with contract monitoring.
   
   The Foundation Trust was committed to working with the PCT to improve healthcare in Tameside.

21. How will the PCT support the Foundation trust by improving services in the community, for example:

1. Access to GP services (Scrutiny Panel)
   
   The Department of Health recognised that Tameside and Glossop had fewer GPs per head of population than other areas in the country and supported the PCT to increase GP numbers. In the last 13 months, three new GP practices had opened and a fourth would be opening shortly. They offered extended opening hours from 8am until 8pm and the Ashton practice had a walk-in-service, so people did not need to be registered with the practice to receive treatment. This offered a substantial change in provision over the previous two years.
    
2. The quality of the out of hours service and the volume of people using the service (Scrutiny Panel)
   
   The PCT had a contract with Go2Doc to provide the out of hours GP service. The majority of Go2Doc employees were local GPs.
   
   Over the last five years Go2Doc had 271,875 contacts, and of these 3,473 had been referred onto accident and emergency services. Approximately 99% of call outs were dealt with either over the phone, via a home visit, via referral to the patient’s GP, or by going to a Go2Doc centre.
   
   The PCT’s contract with Go2Doc was due for renewal in approximately 12 months. The PCT would consider how they could further support the urgent care network when re-contracting the service.
    
3. GP’s awareness and implementation of the End of Life care pathway (Scrutiny Panel)
   
   The PCT had contracts with all GPs in Tameside which included performance measures relating to end of life care. The PCT had worked with GPs to improve their palliative care registers.
    
4. Health prevention and promotion services (Scrutiny Panel)
   
   The PCT’s provider division delivered a comprehensive health prevention and promotion service which helped people to make lifestyle changes with various programmes.
   
   Supplementary question:
   Does the PCT still divert money into health prevention services? (Scrutiny Panel)
   
   The PCT had moved resources from acute to health prevention services. Whilst progress had been made, there was still more for the PCT to achieve in this area.

22. As a major commissioner of these services, what action has NHS Tameside and Glossop taken to resource and promote the development of effective End of Life Care Pathways? (Tameside LINk)

The PCT had appointed a ‘GP facilitator’ to raise awareness of end-of-life care pathways with GP practices and had developed and implemented a toolkit to help professionals make decisions about end-of-life care. The PCT were planning to develop end-of-life care for non-cancer patients and support residential homes to implement end-of-life care next year.

23.

1. Does NHS Tameside and Glossop feel that increased staffing on hospital wards would improve the care that patients receive? (Tameside LINk)
    
2. If so, how do they propose to help the hospital the staffing levels on wards?
   (Tameside LINk)
   
   The PCT’s role was to commission health services from providers, such as hospitals and GPs. The hospital, as a service provider, was responsible for ensuring that staffing levels were sufficient to meet the outcomes required from them.

24. Will NHS Tameside and Glossop make a commitment today to working in partnership with the Tameside LINk, contributing to joint discussions where our members can help to shape commissioning plans for hospital and related services? (Tameside LINk)

The PCT confirmed they were happy to work in partnership with the Tameside LINk.

The Chair thanked the representatives from Tameside Hospital Foundation NHS Trust and NHS Tameside and Glossop (PCT) for attending the conference and highlighted that many factors contributed to high hospital mortality ratios.

The Personal and Health Services Scrutiny Panel and the Tameside LINk would consider their responses to the information in the near future. The Tameside LINk would also be organising a follow-up event in the spring to engage members of the public in these issues in more detail.

Chair