To review the performance of Wye Valley NHS Trust (WVT) in the light of the recent Care Quality Commission (CQC) re-inspection.

Councillor PE Crockett left the meeting for this item having declared a disclosable pecuniary interest as an employee of Wye Valley NHS Trust.

The interim director of nursing, NHS Herefordshire Clinical Commissioning Group (CCG), introduced the item and explained that CCG had been working with NHS Improvement to ensure there were plans in place following the previous inspection of Wye Valley NHS Trust (WVT). There was close working with WVT’s plan to ensure continued improvement.

The managing director, Wye Valley NHS Trust, gave a presentation which highlighted the following points:

·         this was the second inspection of WVT by the Care Quality Commission (CQC), the first of which took place in January 2016 with a finding of Inadequate;

·         WVT had joined up with South Warwickshire NHS Foundation Trust (SWFT) to share good practice;

·         the hospital and the community services gave a good impression, although it had subsequently become clear that the level of focus that WVT had devoted to the CQC inspection appeared to have distracted the organisation from robust financial management, and so the scale of the challenge was to reduce overspending by almost a half;

·         management was working on agreed priorities and taking these forward;

·         SWFT was a stable organisation as a result of redesign and integration of acute services, supported by collective experience and expertise, and so the intention was to draw on this expertise to support improvement by WVT;

·         there was a 10-point plan, focusing on developing A&E safety and quality to bring it in line with the standards of the national A&E plan. SWFT was one of a small number of trusts nationally currently meeting this standard;

·         community redesign was key to improvement, with well integrated pathways and the right capacity to meet demand for services, such as caring for people at home;

·         there was close working with the council to take out duplicated processes and aligning community services

In response to a number of members’ questions regarding waiting times performance, the managing director explained that some waiting times had built up, and it was necessary to address some backlogs. She recognised that this could take at least a year to resolve and that in order to meet certain targets, it was necessary to refer people to other centres.  An impact of the waiting lists was that some pre-operation assessments were repeated to ensure they were up to date.

A member asked if it was a condition of special measures for WVT to form a relationship with SWFT. The managing director clarified that the relationship between WVT and SWFT was in order to ensure a positive journey towards improvement and avoiding a return to special measures.  In terms of financial assurance, the two trusts were believed to have a similar demographic with significant rurality and an urban district general hospital. SWFT remained in balance, with a small surplus and there was confidence in maintaining a good level of service to South Warwickshire residents.  It was possible to turn around the finances in Herefordshire but there were challenges around tariffs, which would not be achieved quickly. However, the aim was to reduce the deficit significantly within two years, although any financial intervention was for NHS England, rather than SWFT, to consider.

In answer to a question from the chairman regarding community hospitals and difficulties regarding organising home care, the managing director acknowledged that outcomes were better for people when cared for at home compared with remaining in hospital. 

A member asked about bed-blocking and cross-border protocols with Wales. The managing director confirmed that there were some difficulties with discharging patients, which it was hoped would improve following work with Shropshire and Powys. Many patients could be cared for at home but the resources were currently hospital based, and this needed addressing, noting that the quality of primary care in the county was good and so local resources could be developed.

The vice-chairman observed that, as there was a high proportion of older people in Herefordshire, consideration needed to be given to complex needs of people presenting to A&E.

The managing director confirmed that the age profile was similar to south Warwickshire, although it was slightly older in Herefordshire. Outpatient waiting times were too high and needed addressing, which could be achieved through the skill mix of staff and building capacity. 

It was envisaged that in quarter one of next year, it should be possible to have a financial plan. It was comparatively more expensive in Herefordshire to provide some services, such as orthopaedics, which currently was operating at a net cost to the trust. It was necessary to address patient flows to support elective work and 7-day services, and there were more efficient ways of providing services such as outpatient prescriptions.

A member noted recent news coverage about reducing agency staff, and commented that South Warwickshire and Herefordshire were not as alike as it might be thought, as Herefordshire was more rural and had a smaller population, and it was essential to recognise difficulties in getting younger workers to come to the county who were put off by its limited infrastructure and facilities. Whilst it was a good aspiration to reduce agency staff, this would not be easy. 

The managing director believed that recruitment and retention could be addressed by nurturing the workforce and by providing good training and opportunities. It was essential to let people know that it could be good to work in the county and have professional and fulfilling careers.  There was more to be done although this might take some time to see the results.   It was not envisaged that the implications of nursing bursaries, such as graduating with debt, would have an adverse effect on recruitment as the use of bursaries meant that the number of training places had previously been capped and there had already been some recruitment into a number of specialties.

A member commented on the sustainability and transformation plan which showed a slight increase in the number of hospital beds and a reduction in community beds, and that in order to achieve aspirations to get WVT into sustainable financial position, it would accelerate the volume of discharges, such that there was a risk that the system would not be able to cope with the additional demand.  The only options on discharge then would be to go home or to go a care home, which was expensive and needed funding. The situation was unsustainable and there was a question over whether SWFT has unrealistic aspirations.

In response, the managing director explained that it was about reducing whole system’s costs and working together to avoid duplication. The ambition was to keep people at home whilst achieving financial balance for both health and social care. 

The director for adults and wellbeing added that Herefordshire was comparatively lower than neighbours in placement rates for older people and that it was not the intention to discharge people unnecessarily, however, being in hospital reduced a person’s ability to care for themselves and so they would be discharged as soon as possible when medically fit.  Guidance was awaited on the better care fund, but there was opportunity to take services forward through this scheme in an integrated manner.

A member noted that the mantra of people needing to look after themselves was well used, and the success of earlier work had not been fully realised, such as falls prevention, and so the concept of self-care and prevention needed attention. 

It was noted that there was much work to be brought together on this, such as development of frailty pathways. The chairman commented on an increasing dependence on the voluntary sector, making the observation that many volunteers are elderly themselves and would not be able to take on what was expected of them. 

Commenting on experience of previous public consultations, a member highlighted the importance of members having access to plans in writing in order to see the details to be able to explain them clearly to their constituents.   It was also noted that there needed to be greater connection to management and for there to be sound and stable leadership in order to effect change. There was a well-established leadership within SWFT.

The chairman asked about practicalities for SWFT with the STP footprint being across Herefordshire and Worcestershire. The managing director confirmed that SWFT was committed to the STP footprint and ensuring the clinical network was robust.  She added that it might be beneficial to spread services across a wider area but it was important to have services in Herefordshire. Some service models might need reviewing but there was no proposal to move services. In addition, the financial trajectory needed agreeing with NHS England.

The managing director provided assurance that SWFT’s role was to help and support and to make things better. There were no plans to merge the two organisations, although there was some value in exploring corporate and back office functions sharing expertise.   

A member asked for details on costs for discharge pathways, commenting on ensuring they are appropriate. It was clarified that the typical cost was in the region of £2300 per week for hospital care, compared with around £150 for care at home. Experience in South Warwickshire showed that changes to discharge pathways allowed throughput to be quadrupled.

The vice-chairman added that Herefordshire’s hospital services were better than might be believed, and asked what improvements could be committed to within 12 months.  The managing director identified that enhanced out of hospital services would be delivered and services would feel different to the public.  A member added that it was essential to engage carers at home to ensure continuity of care after discharge, but it was also important to note that pre-admission fitness was a factor in recovery time.

RESOLVED

That an update be provided to the committee in March 2017.