Agenda item

An opportunity for Councillors to ask Helen Brown and Esther Moors (WHHT) questions about the presentation delivered to the Membership on 25 January 2018. (presentation slides are included in pack for reference)

HBrown advised that an update was provided when they attended just after Christmas and Katie spoke to the CPC report.  I think that most of the people in the room were here and heard that or have probably picked up some of the key messages since then.  I wasn’t proposing to do a big representing of the findings but I’m very happy if people have got questions that they would like to ask me about to take those and if necessary to go and find the answers if I can’t answer them today.

Cllr Taylor added that that because following that private conversational meeting, the slides, together with the slides for the Herts County Council, the two Herts County Council reports as well, were distributed, so they are in the pack before us all tonight.

HBrown further commented that overall we’re pleased to have come out of special measures, made a lot of progress in a lot of areas.  Emergency care is our big pressure point and improvements at Hemel in the services that are rated by the CQC but that’s a relatively small part of the overall CQC picture because they focus more on the services that are offered.

Cllr Timmis referred to A&E services and asked whether, as in Luton and Dunstable, there is a GP service running alongside? To siphon off the patients who are neither accident nor emergency?

HBrown responded that we don’t have exactly the same service model as Luton, but we do have GPs working in our Minors’ section of A&E, and we have quite a complex kind of set of triage and streaming arrangements but yes, people walk in, they get an initial assessment by a Triage Nurse and if their needs can be met by a GP or a nurse, they get streamed to Minors.  If they need to see a consultant or a specialist they go through to Majors.  We’ve had lots of people come and look at our A&E model including Pauline Phillips, who’s the national emergency care lead and the Chief Executive at Luton and Dunstable and she has confirmed that she thinks our model is good and that we’ve got good arrangements in place for patients who prevent the flow of complexity needs.  Actually at Watford, it’s less of an issue than it is for many other areas in Hertfordshire.  We don’t have such a high proportion of public care attendances as other A&E departments do. 

Cllr Timmis further queried; do you have an emergency ward, so that patients whose decision has not been made, at least don’t necessarily go up at all aren’t being held up?

HBrown responded to advise that there is a whole range of alternatives, so yes, because, there are lots of different decisions that get made for patients who come through emergency care, sometimes you can go home, with ongoing care with your GP or outpatient follow up.  Sometimes it’s you definitely need to go through for an admission and we need to make that happen as long as possible and often, there’s a period of more assessment needed to make the best decision and to provide treatment and we’ve got a range of different assessment areas, an ambulatory treatment centre and medical assessment unit, a clinical precision unit, a children’s observation bay, one of the challenges we’ve got at Watford is that our buildings are not great, some of them are quite small and fragmented.  Ideally, we’d have them more streamlined than that.  The other issue we’ve got at the moment is we’ve got bedded patients in all of those areas, so we’ve got a hundred and twenty additional beds, what we call search beds, open over and above and we have got patients receiving in patient care in every single one of those areas that I’ve just described.  Actually, not quite all of them tonight, as of 8 o’clock but probably by 8 o’clock tomorrow morning, we will have.  So we have got a real challenge and since Christmas, we’re not alone in this, the national picture’s similar but since Christmas it has been really, really busy and the difficult position you get into is once you’ve opened additional beds, you’ve got your staff spread thinner, it is then very difficult to run an efficient care model and people’s length of stay increases, so you get into a bit of a vicious circle. 

Cllr Hicks responded and asked, you said that Watford doesn’t get as many non-urgent care, is that because Watford has got an adult all night doctor’s access or is there any other reason because we need to understand why that is and try to bring that over to the rest of the County?

HBrown responded that it is a statement that really compares us to the broader national picture.  Our numbers are probably closer to twenty-five percent to thirty percent.  It’s difficult to, and I don’t know how that compares to the Lister and L & D.  I think L & D’s numbers are closer to the national picture or higher.  I don’t know about the Lister.  The most significant factor that governs A & E attendances is access to primary care and proximity.  So, when you look at GP practices, the closer you are to an A & E Department, the more likely your patients are to attend that A & E Department, particularly with lower level needs.  Obviously, the higher up the spectrum you get, the more it evens itself out.  Our best understanding is that, so in Watford, for example, they’ve implemented extended hours and they were a national pilot for extended hours.  It has now been ruled out across Dacorum and the whole of Herts Valleys but we think that that has had an impact on the number of people coming to A & E with lower complexity needs. 

Cllr Taylor responded to what was said about L & D, because you’ve heard me say before that unfortunately I had to experience L & D a number of times over the past, well go back six months, the two and a half years before that, we attended L & D twelve times and it was interesting to see how they did the triage and then you were seen, as you say, in order of severity of your problems and on every occasion we were quite impressed by the way it was streamlined and only once did we have to be put on a ward for half an hour because we’d come up with the maximum four hours in A & E and it’s interesting that the Chief Exec of A & E at Luton and Dunstable has been talking to Watford.  That is, I think, is quite gratifying for someone who has had to experience that problem at first hand.

EGlasser commented on having viewed the BBC figures and for A & E we were doing I think, eleventh from the bottom, out of the whole of the country.  Now, why is that, and how can you resolve it?

HBrown responded that they watch the rankings very carefully, so there are one hundred and thirty-seven A & E Departments or hospitals with A & E across the country.  We are often in the bottom ten and we had a period when we managed to put ourselves higher up the table before Christmas and It’s difficult, the key issue is four hour breaches are only one element, we are really concerned about waiting times in A & E and the amount of time people wait to get admitted to hospital in particular and the experience that people have, but all of our clinical outcomes are good, we’ve got low mortality, we benchmark better, we’re at the top of them, so converse to any performance where we are in the bottom ten percent, for mortality we’re in the top twenty percent.

Cllr Taylor commented that is very odd.

HBrown responded that it’s not very odd, it’s different things.  For example, sepsis which people may have heard about last week, sepsis awareness week, how important it is.  We’ve done a lot or work on early identification of sepsis, we audit that and our performance on sepsis is, again, in the top twenty-five percent for the country.  So I don’t want to say that waiting times aren’t important because they really, really are and we really worry about it and we get an awful lot of pain and grief from politicians and the system on our A & E performance but it is only one aspect of the care.  The majority of breaches in our A & E Department are the patients waiting for admission.  So, we have what we call two pathways.  Non-admitted pathways, where you go home and admitted pathways and the majority of the challenge that we’ve got is on the admitted pathways, for patients who’d go on to need in patient admission and we can’t pull them through from A & E quickly enough, into beds and that is because our bed occupancy is too high and the number of patients needing an admission and the amount of time that individual patients stay in the hospital it is more that our bed base can maintain at the moment.  We will talk a bit more about that when we talk about delayed discharges of care and I’ve got a presentation here which shows you some of the data we look at on a regular basis.  It’s mainly, it’s not exclusively because the other thing that happens is when your A & E gets overcrowded because you’ve got twenty or thirty patients waiting for admission, you haven’t got enough space to do all the assessments in a timely way.  So it does have a knock on impact.  It’s a shame that the others aren’t here tonight because it really is a whole system challenge, it’s not just a hospital challenge

EGlasser commented that there was something in the Gazette today, not sure if everyone has seen it.  It’s a staff survey and it says almost half of all staff at West Hertfordshire Hospitals Trust would not recommend it as a place to work or as a place to receive treatment, according to the latest national NHS survey.  Bad news.

HBrown responded that there is a staff survey that’s done every year.  All staff get asked the same question across the whole of the NHS so it does give you a good opportunity to benchmark.  We can share the full report with you because obviously what you have got there is just the highlights, or the lowlights.  In fact you’ve got the lowlights of the staff satisfaction survey.  Overall, many of our scores, so a) we’ve seen significant improvement over three years.  We score very highly in a number of areas but the two questions that we score least well in and don’t really correlate to the other scores we get are; would you recommend it as a place to work and would you recommend it as a place to get treatment, and that is a concern for us and we want to understand why.  We’ve been running some focus groups with staff to kind of get underneath some of the figures and understand why people are saying that and they are related to each other, so our buildings, our IT.  They impact both on what it’s like to work at Watford and how people feel about the care they are able to give.  So from privacy and dignity, and then all of the things that we’ve just discussed about A & E, all of the staff in the hospital are really disappointed that we can’t do better and it’s really frustrating for them.  The conditions are so hard and yet they see that patients are not getting what they would like their patients to get.  So I honestly think you should see the full results because you would see a much rounder picture and you’ll see that a lot of staff are really positive about their colleagues, about team working around leadership, around personal development, around support for health and wellbeing but those two questions, which are the top line, most important questions, are the ones that we do much worse on and it’s unusual.  Our profile on those answers is unusual because normally if you are getting the kind of scores we’re getting on the other questions, those questions are higher.  We are unusual that we’ve got such a gap between them, so I obviously think that buildings, infrastructure and emergency care questions are the things that are resulting in those answers.

EGlasser asked if HBRown would mind circulating the survey.  HBrown confirmed she would.

Action Point: HBrown to circulate the full full WHHT staff survey to the Committee.

Cllr Maddern referred to a case she was aware of where a seventeen-year old schoolgirl was in a hospital bed at Watford for four months, with people dying, literally, dying in the beds next to them because it was a whole ward of elderly.  Cllr Maddern asked; what is the hospital is doing about trying to put teenagers with teenagers, rather than with eighty- or ninety-year old people who are dying.  Is there something that the hospital can work on in that please?

HBrown responded that she is not able to give a full answer on that without going back to my other director and nursing colleagues.  We’ve obviously got Starfish Ward which is for children and young people and we do treat teenagers on Starfish Ward and actually by the time you’re getting sixteen, seventeen, eighteen, what happens is an individual kind of clinical decision about whether your needs are best met in the children and young people’s setting or whether your needs are best met on one of the other wards.  So, for example, we sometimes have young women with gynaecological problems and they are more appropriately managed on the gynaecological ward.  One of the challenges we’ve got and I hate to keep coming back to the same issue but our gynaecology ward at the moment has got very few gynaecology patients and it has got fifteen plus medical on it and I’m afraid our medical patients tend to be older.  So, where ordinarily the gynae ward would have more of a patient mix, younger women, middle aged women, at the moment, now I’m not saying, this patient may not be on gynae, but what they try to do at that age is make an individual decision.  I must say, the vast majority of our patients are older and there isn’t enough activity in that young adult group to create ring fence facilities for the full range of the kind of conditions.  One of the, I want to say when we get our new hospital and when we get our major redevelopment, which we are still working to try and get, we will look at whether we can create a young people’s part of the paediatrics unit.  The other thing we need is more side rooms.  At the moment because of the infrastructure of the hospital we’ve only got about fifteen to twenty side rooms in total and they have to be prioritised for infection control.  If we could have more single rooms, then this situation wouldn’t arise

Cllr Hicks added a comment to say that a lot of people don’t like being in private rooms, it gets lonely and isolated.

HBrown responded that the ideal solution is to have a mix of both.  The hospital guidance if you build new-build hospitals say that you have to have fifty percent, in fact it might even say all the rooms have to be single or fifty percent.  We’ve talked about it and we don’t think, we think that you’re right, that not everybody wants a single room.  Ideally we would create a younger person’s unit but the demand isn’t that high and that’s the challenge

The Chair rounded up, thanked HBrown for answering questions and offered congratulations to everyone who worked so hard at every level and every role at West Herts Hospitals Trust to get the Trust out of special measures.  Whilst we in Hemel Hempstead are not happy with there being so few services at Hemel Hempstead, it is good news that none of the services at Hemel Hempstead that were rated, were rated as inadequate, so well done for all the work that you’re doing and now we’ve acquired improvement, we look forward to seeing the improvements.