To consider the issues and challenges facing the Trusts.

The Chairman welcomed the representatives from the three Trusts and invited them to each give a short presentation on the issues and challenges facing their respective Trust.

Herefordshire Primary Care Trust – Julie Thornby – Director of Corporate Development.

Ms Thornby reported that the Herefordshire Primary Care Trust (PCT) had been formed in 2000 combining the Herefordshire Primary Care Group; NHS Community Trust and Health Authority.  The PCT was responsible for patients registered with Herefordshire General Practitioners (GPs), with 100 commissioning staff, 1200 provider staff, a budget of £233m and facilities throughout the County.  The area covered by the PCT was co-terminus with that of the Council, an advantage of which was the joint working arrangements particularly in the area of Social Care and Health Care.

She highlighted the four key functions of the PCT namely: Commissioning (plan and purchase) health and care services – ranging from contracts for the community as a whole to an individuals specific care needs; Promote and protect public health – through initiatives against obesity, smoking or alcohol; Work with primary care (GPs, dentists, pharmacists, opticians), and the delivery of community and mental health services (provider services).

She outlined the structure of the PCT Board (Executive and Non-Executive Directors), a number of committees and the relationship with the Hereford Hospital Trust (commissioning services) and the West Midlands Strategic Health Authority (responsible for overseeing performance management).

She highlighted a number of challenges namely:

• Patient access to service target of 18 weeks wait (from first referral to treatment);
• Developing and modernising services e.g. unscheduled care and she gave examples of developments in mental health contracts and the use/delivery of A&E services,
• Reducing health inequalities further details of which may be covered by a future presentation to the Committee by the Director for Public Health.
• The national initiative to expand choice and diversity for patients and the need to ensure that local providers provide the sort of services expected. She suggested that the younger generation may more used to shopping around for services and therefore be more inclined to elsewhere for treatments.
• Ensuring financial balance.
• Working with local GPs to further develop practice based commissioning.
• Building on various options that may arise from the Public Service Trust and ensuring that there was a clear separation between commissioner and provider.

Hereford Hospitals NHS Trust – Martin Woodford – Chief Executive.

Mr Woodford reported that it was a small Trust when compared to Trusts nationally (317 beds serving 230,000 population in Herefordshire/Powys) with 1364 full time staff; £91m turnover (2006/07) and a significant overhead (£12m) of PFI hospital.  He put this in the context of: providing patient choice; GP practice based commissioning; payment by results (based on a national scale); competition from independent providers and working towards a Foundation Trust in 2008.  Operating from a PFI building the Trust had two main commissioners namely Herefordshire PCT (85.4% of income) and Powys Local Health Board (9.2% and increasing).  The catchment area had a significantly higher population of over 65s than the national average (20% compared to 15%) and that upward trend was set to continue (with a 50% increase in over 65s by 2020).  The Trust consistently exceeded national performance targets and he outlined performance in emergency medicine; elective surgery; maternity; out patient and local cancer services.

He highlighted a number of key achievements namely: attaining financial balance for the last three years with the aim of achieving a financial surplus in 2007/08; exceeding key access targets; through a jointly funded venture with Macmillan Cancer Support the establishment of a state of the art Cancer Unit by 2009; being top performer in the West Midlands for a range of services; being recognised as one of the top 40 UK hospitals by independent benchmarking experts (CHKS) and achieving ‘Practice Plus – Improving Working Lives’ status.

He explained the key challenges facing the Trust, together with appropriate commentary under the following themes:

Involving patients:

1. Meeting the 18 week access target from referral to treatment by end of 2007 (a year ahead of the rest of the NHS).  In conjunction with the Herefordshire PCT, the Trust had been chosen as an early achiever of the 18 week referral to treatment target.  Attention was also being given to the system of capturing the relevant statistics.
2. Reducing or even eliminating the incidence of hospital acquired infection.  This was being addressed through the implementation of a new anti-biotic prescription policy and initiatives aimed at educating staff, visitors and patients in the importance of infection control.
3. Engaging public and patients to improve the patient experience and developing a reputation for quality.  The Trust would be both increasing their public membership base and working together with patient interest groups to help improve services.  It also intended introducing a Quality Improvement Programme.

Involving the Trust:

4. Reducing the pressure on hospital beds by working more closely together with colleagues across the health and social care community.  The Trust would focus on reducing the pressure of unscheduled care.  He acknowledged that there was an upward trend in emergency need for beds and that three of the hutted wards were still in use.  However, efforts were being made to re-shape the hospital to close the hutted wards but keep the bed numbers.
5. Using the potential of IT to improve care.   This would be through developments to electronic discharge information and the completion of electronic health records.  The GP online ‘booking’ service was in development.
6. Putting the Trusts finances on a firmer footing and working smarter.  The Trust were working on creating a financial surplus, using the LEAN approach to working more efficiently.
7. Closing the hutted wards and improving the organisation of care.  As mentioned earlier the Trust intend delivering a site Development Plan.
8. Collaboration with other stakeholders in Cancer Care.  Through partnership working with Macmillan Cancer Support to open a new cancer unit and to resolve the debate regarding radiotherapy provision.

Working with stakeholders:

9. Promoting the Trusts services to GPs and providing improved out-reach services e.g. into Community Hospitals.  The Hospital Senior Clinical Teams regularly met with GPs to improve services and further improvements in chronic disease management programmes were planed.
10. Working more effectively in partnership with commissioners / stakeholder organisations to deliver seamless care.  The Trust would maintain and improve relationships and ways of working with partners to address the targets.

The Committee noted that the responsibility of the Care Pathway Officer would focus on the strategic issues rather than the mechanism of moving patients through the hospital system.  Following a brief explanation of the working of the national scale of charges e.g. for a hip operation, the Committee noted that no problems had been experienced in financing care for migrant workers.

Responding to questions concerning the capacity of the hospital site, particularly with the expected growth in the over 65s population and the business expansion of the Edgar Street Grid, the Committee were informed that the Trust were already working with both the PFI Contractor and the Council’s Planners to revise the site and ensure the optimum utilisation of space.

West Midlands Ambulance Service – Malcolm Price – Divisional Manager (Herefordshire)

Mr Price outlined the local management team for the service; the facilities served namely the Hereford Hospital and the four minor injury units in the County towns and the ambulance stations their staffing, vehicles and facilities at Hereford; Leominster; Bromyard; Ledbury and Ross-on-Wye.

He reported that the service was dominated by response targets namely Category A – 999 life threatening (target 75% of calls reached in 8 minutes) for which last year Herefordshire achieved 75.2%.  Category B – 999 but may not be life threatening (target 95% reached in 19 minutes) for which last year Herefordshire achieved 91.9%.  Category C  - 999 but may not require hospital or ambulance and Category Urgent – request by GP at practice for patient transportation to hospital.  He also provided statistics on pre hospital Thrombolysis and ROCS (Return of spontaneous Circulation) after cardiac arrest; attendance at incidents; hospital turnaround times and paramedic skill mix, of which Herefordshire had a high percentage of paramedics compared to nationally.

He further reported upon staffing issues namely: that staff may take career breaks; development reviews were undertaken; flexitime working and family leave was available, and alternative treatments e.g. the Bowen Technique, were being introduced along with ‘C Max’ chairs (motorised chair for stairs) and Bariatric stretchers (for larger patients)

The Committee noted that in relation to the positioning of vehicles when not on a call, it was explained that the vehicle may not return to a station but would be temporarily positioned at a strategic location to try to ensure the best coverage for the County.

Questioned on why Kington did not have an ambulance station the Committee were informed that the number of call outs per day did not warrant a station.  The area did however, in addition to the local GPs have a number of Community First Responders (CFR) who were trained in the use of oxygen and defibrillator.  Further CFRs were being trained throughout the County.

Responding to questions on the number of vehicles/personnel that may attend a call at a household the Committee were informed that where an ambulance may initially attend the situation was assessed and it may then be considered that the situation could be effectively dealt with by other means e.g. District Nurse or Emergency Care Practitioner, thereby negating the possible need for hospitalisation.

The Chairman thanked the presenters for attending and for informing the Committee about the challenges facing the individual Trusts.