To review the quality and sustainability of  services commissioned by the Herefordshire Clinical Commissioning Group (CCG) from Wye Valley NHS Trust (WVT) on behalf of the population of Herefordshire.

The accountable officer, Herefordshire Clinical Commissioning Group (CCG) and the manging director, Wye Valley NHS Trust (WVT) presented the slides (appendix a).  A number of key points were highlighted:

•      Wye Valley NHS Trust was the major health service provider commissioned through a contract of £118million funded through the Department of Health. The Trust received additional income from out of county patients, for example Powys, contributing some 20% of WVT income.

•      WVT had been lifted out of special measures by the Care Quality Commission in 2016 and was now rated as “requires improvement”.  A new leadership team was making a difference to performance along with other factors including One Herefordshire, with organisations working together as part of the wider health and social care family. WVT had identified clinical and organisational priorities for 2017/18 to help sustain improved performance.

•       The financial context of WVT was not unique, as it was not unusual for small rural hospitals to have financial challenges because of how the national funding formula worked. However, there was a cost improvement programme in place for 2017-18 that was designed to reduce the deficit to between £15m and £20m.  The sustainability and transformation plan was designed to support efficiencies in service provision as a contributing factor.

•    The most significant performance targets reflected local needs and concerns. In particular:

o   the CCG and WVT had created a plan that had enabled additional funding to be secured to meet the national standard requirement for 92% of patients to be seen within 18 weeks of referral

o   There was work to do around continued improvement in A&E performance. However, it was noted that the national standard was met in Warwick and the new leadership arrangements, with links to South Warwickshire Foundation Trust, would provide access to good practice approaches to make a difference in Hereford

o   Cancer services were improving and all standards had been achieved in May

o   Steps were being taken to ensure that delayed transfers of care were improving and to work towards a model of ensuring people are supported to leave hospital with the right care at home.

•    The future performance of WVT would be supported through the contract with the CCG, and ensuring this worked in the best interest of population. There was increasing opportunity with other NHS providers and the voluntary and community sector working together to support this.

During the presentation members raised a number of questions and comments, with the following responses offered by officers:

In answer to a request for more detailed information on how money is spent, it was explained that it would be possible to provide a breakdown in the portfolio of contracts, although it should be noted that much of the income was driven by national arrangements such as the GP contract and so there was little discretion around price of services. 

In terms of out of county patients and particularly in relation to Powys services, there was a good relationship and there was a degree of discretion around charges as well as some national drivers. It was noted that systems in Wales were more paper-based than in England, where most referrals were electronic.

The managing director would be full-time at WVT from September as part of the new leadership team in partnership with South Warwickshire Foundation Trust. The new arrangements would support continuous improvement and strengthen WVT’s sustainability as a small district general hospital.

A member commented that staff at the hospital were giving good feedback and asked what support was available for staff when they had difficulties.  It was confirmed that there was much available to support staff health and wellbeing and staff engagement.

It was acknowledged that recruitment was a challenge for public services. A significant driver in needing to address recruitment and retention of nurses was the expenditure on agency workers. Progress was being made on medical recruitment in Paediatrics and in Obstetrics and Gynaecology.  A new single agency supplier scheme would be starting in September to help manage the rates paid to agency workers, but there remained the element of competition and market forces with particular agencies paying significantly higher rates.

A member welcomed the focus on managing sepsis but commented on the early management of deteriorating patients and the link to reducing mortality as an inherent activity. It was acknowledged that in comparison with national figures, WVT had a higher rate of mortality than expected and this needed to be understood in more depth.  There was a range of steps to address these linked clinical issues, and improving discharge pathways and urgent care performance was part of this.

A brief discussion took place on this issue, noting possible links to rurality and how vulnerable or isolated people are noticed in order to address problems before they escalate. Public health, communities and parish councils played a part in this and it was important for professionals to keep in touch with local issues to support early intervention.

The financial summary was welcomed and to clarify further, it was explained that in relation to the term ‘structural deficit’, there were elements relating to commitments such as PFI (private finance initiative) that were not currently possible to address, but there was some £20m which was being addressed.  A member commented on the interest spent on borrowing whilst other services were being supported centrally by government and queried whether a line could be drawn under this to allow WVT to move to a better financial position. It was clarified that deficits were expected by NHS Improvement to be resolved and to cease reliance on drawing upon future funding.

A member asked with regard to a national push for achieving economies of scale, what was the likelihood of funding being diverted away from the county hospital and services moved to other providers. It was the view that the people of Herefordshire and Mid-Wales needed a district general hospital with necessary services but unlike other counties, there were no alternative sites and it was the intention to protect these services. However, it was important to emphasise that ultimately this would be for central government to determine.  A member suggested that financial sustainability needed to be explored further by the committee as a specific item.

Officers were congratulated on securing the additional £2.9m funding to meet the 18-week standard referral to treatment time. To provide more detail on how this would be used, it was explained that it would enable WVT to pay for additional workforce time and for directing referrals to other providers as temporary measures until the issue was addressed. It had been possible, drawing upon previous experiences, to demonstrate to NHS England that the additional funding would be used wisely.

With reference to historic issues from 2015 regarding referral letters not being received, it was confirmed that the CCGs in Worcestershire and Herefordshire were working together to resolve referral routes and funding for treatment and to ensure that referrals into Herefordshire came with funding.  

It was clarified that the term streaming used in the presentation referred to establishing primary care resources into the system to compliment services and support improvement although this was dependent on how the workforce was planned and designed and it would take some time to build capacity.

Responding to concern regarding ability to respond to winter pressures, assurance was given that WVT was in a better place to respond although a bad winter would be a significant pressure.  Winter planning had already started and there were plans identified to respond to pressures and prioritise urgent care. It was felt that Herefordshire responded comparatively well to winter pressures. 

With reference to any increase in numbers at A&E since the closure of the walk-in centre, it was noted that although it would be reasonable to expect some impact, there had been a small decrease since 28 July and people had not presented to A&E. A member thanked officers for ensuring there had been a member of staff at the site of the former walk-in centre to signpost people.

A member noted that there had been some recent press commentary regarding waiting times for colonoscopies. Assurance was given that cancer services were performing well and diagnostic services were at 99% achievement of responding within 6 weeks of referral and this had been maintained for 18 months. It was noted that in relation to mortality, although people moved to hospices for palliative or end of life care, the performance in diagnostics and treatment waiting times did have an effect on general mortality rates.

With regard to delayed transfers of care, it was acknowledged that some people remained in hospital when they could be cared for elsewhere and this was being addressed to ensure better patient care and reduce reliance on hospital beds. The delays were attributed to management of discharges for people outside the county rather than within Herefordshire. However, it was noted that there was an increasing demand for care at home that was challenging to meet, although the aim was to work to a model which supported people to be assessed for ongoing care back at home rather than in hospital. A member commented that transfer pathways could be developed for use as soon as someone was admitted to hospital so that care was planned at the outset. Officers confirmed that this was the aspiration as there were predictable elements that could be put in place in advance of need, although it was noted that this relied on support being in place at home and resources available in the community such as through the community and voluntary sector. 

RESOLVED

That

a)    Improved performance of Wye Valley NHS Trust and plans for continuing improvement, as supported through contractual arrangements with the Clinical Commissioning Group, be noted; and

b)    Financial sustainability of Wye Valley NHS Trust be included as a specific area for further scrutiny in the committee’s work programme.