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Maidstone Borough Council
External Overview and Scrutiny Committee
Tuesday 18 November 2008
Health Services in Maidstone
Report of: Senior Overview and Scrutiny Officer
1. Introduction
1.1 The External Overview and Scrutiny Committee has within its remit “providing a scrutiny role of outside agencies” and “health related issues”.
1.2 The Committee last interviewed representatives of NHS West Kent (formerly the West Kent Primary Care Trust) and the Maidstone and Tunbridge Wells (MTW) NHS Trust on 25 February 2008. A wide range of topics were covered at this meeting, including:
· The Healthcare Commission report into the outbreaks of Clostridium difficile (C.Diff) at the MTW NHS Trust;
· The financial recovery plan in place at the West Kent PCT;
· Health priorities in West Kent;
· Mental health services;
· The potential PFI (Private Finance Initiative) Hospital at Pembury;
· Maternity services;
· The reconfiguration of services between Maidstone and Kent and Sussex hospitals;
· Methods of consultation;
· Training of junior doctors;
· Stroke services;
· Partnership working;
· Preventative medicine;
· Local Involvement Networks (LINks);
· ‘Bed blocking’ and ‘ambulance stacking’;
· Dentistry.
Copies of the full minutes of the meeting are available on the External OSC page at www.digitalmaidstone.co.uk/osc or by contacting Louise Smith, Senior Overview and Scrutiny Officer, on 01622 602524 or louisesmith@maidstone.gov.uk.
1.3 The following representatives will be in attendance at the meeting to update Members on healthcare provision in Maidstone and to outline future plans:
· Steve Phoenix, Chief Executive, NHS West Kent.
· Julia Ross, Director of Civic Engagement, NHS West Kent.
· Glenn Douglas, Chief Executive, Maidstone and Tunbridge Wells NHS Trust.
Members are recommended to consider this update and discuss any issues or concerns that they may have with regard to this, with the witnesses.
2. Health Provision in Maidstone
2.1 NHS West Kent is responsible for managing all primary care services:
· GPs
· Dentists
· Opticians
· Pharmacies
· Walk-in centres
2.2 NHS West Kent is responsible for planning and commissioning services and controls 80% of the NHS budget for West Kent. This includes providing funding to NHS Trusts.
2.3 NHS West Kent is the new name for the West Kent Primary Care Trust (PCT), though it is still a PCT. These names will be used interchangeably throughout this briefing note, as much of the information refers to the organisation prior to its name-change.
2.4 The Maidstone and Tunbridge Wells NHS Trust provides general hospital services and specialist care. It manages three main hospitals – Maidstone, Pembury and Kent and Sussex.
3. Annual Health Check for NHS West Kent
3.1 The 2007/08 Annual Health Check for NHS West Kent rated the PCT’s performance as “fair” for use of resources and “weak” for quality of services. It also found that it had not met core standards or existing national targets, and was “weak” in relation to new national targets. Further details about each of these sections are available in paragraphs 3.4 to 3.9.
3.2 In response to the Healthcare Commission’s ratings, the Chief Executive of NHS West Kent, Steve Phoenix, stated:
“While I am disappointed about the rating of “weak” for quality of services, it is what we were expecting and is in part due to issues that have been longstanding in West Kent. Furthermore, it is no secret that 2007/8 was a turbulent year for the local health economy in West Kent. We are on a journey to improve services and I am confident that we are making steady progress.”
Mr Phoenix also highlighted that:
“although an important measure of NHS trusts’ performance the Annual Health Check looks at only a portion of the services we provide. There are many areas not included in the assessment which are of great importance to local people – such as the dedicated stroke units and daily “mini-stroke” clinics in West Kent that we are funding, the work we have done with GPs to extend practices’ opening times, and the £3.2million investment we are making in dentistry.”
3.3 The information in the following sections was obtained from the Healthcare Commission website at www.healthcarecommission.org.uk.
3.4 Use of Resources
How Primary Care
Trusts Performed: 5.3% Excellent 45.4% Good 45.4% Fair 3.9% Weak West Kent PCT 2007/08: “fair” West Kent PCT 2006/07: “weak”
3.4.1 The Healthcare Commission’s comment on the West Kent PCT’s use of resources was as follows:
“This organisation has at least met the basic requirements in four of the five areas of this assessment and has been given a score of fair for use of resources. The organisation has met all of its financial targets for the past two years and its consideration of value for money was found to be good. However, financial reporting was considered to be weak.”
3.4.2 Use of Resources is assessed from 1-4 by the Audit Commission and covers five areas. The PCT’s scores[1] for these were as follows:
· Financial reporting: 1
· Financial management: 2
· Financial standing: 3
· Internal control: 2
· Value for money: 3
3.4.3 At the meeting of the External OSC on 25 February 2008, Mr Phoenix detailed the ways in which the Trust was tackling its financial problems:
“In the year 2007/2008, the PCT had approximately£20 million of accumulated debt. A financial recovery plan was in place and the PCT was on track to repay this debt by the end of the financial year. The financial recovery plan was a two-fold strategy. Growth had been restricted where possible and appropriate, and services were being delivered to the same standard but in a more efficient way, for example the use of generic rather than branded drugs. Also, discretionary spending had been cut, for example non-mandatory training and development programmes for staff. One benefit of these cut-backs and restricted growth was the release of resources to support other NHS organisations in the area, such as the MTW NHS Trust. Consequently, for the first time in a significant period, the whole of the NHS in West Kent was expected to be in financial balance at the end of the financial year.”
The improved “use of resources” rating for the Trust confirms the success of the financial recovery plan.
3.5 Quality of Services
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3.5.1 The trust automatically scored 'weak' for quality of services because it scored 'not met' for both core standards and existing national targets (detailed below).
3.5.2 The “quality of services” score is informed by the ratings for core standards, existing national targets and new national targets.
3.5.3 Local feedback is also used to assess the performance of the NHS, in particular in relation to core standards. Sources for this include community groups, Patient and Public Involvement Forums (now Local Involvement Networks) and NHS Overview and Scrutiny Committees. Types of evidence can include the notes of a meeting with or a visit to a trust, the results of a local survey, or people's personal stories.
3.6 Core Standards
How Primary Care
Trusts Performed: 53.3% Fully met 32.2% Almost met 9.9% Partly met 4.6% Not met West Kent PCT 2007/08: “not met” West Kent PCT 2006/07: “almost met”
3.6.1 The core standards represent the minimum standards for services that must be met, for all patients, by all NHS bodies. This year, the PCT was assessed as not meeting the core standards, compared to a rating of “almost met” in 2006/07.
3.6.2 Mr Phoenix, in response to the Healthcare Commission’s assessment, highlighted that although the PCT was assessed as not meeting core standards, this was because full-year compliance with these was required; the PCT is in fact now meeting the majority of these standards.
3.6.3 The Health Check identified that the following core standards as not being met or they had received insufficient assurance that they were:
· C18 - equity, choice
· C05c – updating clinical skills
· C07a and c – governance
· C07e – discrimination
· C08b –personal development
· C09 – records management
· C11a – recruitment and training
· C11c – professional development
· C13c – confidentiality of information
· C23 – public health cycle
· C04c – decontamination
3.6.4 The PCT put in place a dedicated action plan to address these issues and is now compliant in all but the following core standards:
· C09 – records management – The PCT declared insufficient assurance with this standard because: “The PCT’s records management policy was ratified on the 18th of March 2008, therefore leaving a short time for implementation and monitoring against implementation. Monitoring against implementation is limited to audits in specific areas.”
· C11c – professional development - The PCT declared compliance- with this standard, however, following the Healthcare Commission inspection visit on 30th June, the HC concluded that there was inadequate evidence to demonstrate reasonable assurance for the full year.
· C13c – confidentiality of information – The PCT is undertaking a review of all existing contracts to ensure the inclusion of Data Protection Act, confidentiality, Information Security and Freedom of Information Clauses; this is due to be completed by the end of 2008 and compliance with this standard for 2008/09 depends on the results of this review.
3.7 Existing National Targets
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3.7.1 The Audit Commission states that “by looking at whether organisations are meeting existing national targets set by the Government we can get a better understanding of, for example, how long patients have to wait for care and treatment in the NHS. Healthcare organisations must be able to demonstrate each year that they are meeting these targets[2].”
3.7.2 The West Kent NHS achieved 9 of these targets but did not meet a further 8. The 8 targets not met or underachieved on were:
· People with diabetes to be offered screening for the early detection of diabetic retinopathy (complication caused by diabetes that causes problems with vision and can lead to blindness);
· Maintain a maximum wait of 26 weeks for inpatients;
· Maintain a maximum wait of 13 weeks for an outpatient appointment;
· Maintain delayed transfers of care at a minimal level;
· Deliver a ten percentage point increase per year in the proportion of people suffering from a heart attack who receive thrombolysis within 60 minutes of calling for professional help;
· Every hospital appointment to be booked for the convenience of the patient, making it easier for patients and their GPs to choose a hospital and consultant that best meets their needs. Patients should be able to choose from at least four health care providers for planned hospital care;
· Update practice-based registers so that patients with coronary heart disease and diabetes, and the majority of patients at high risk of coronary heart disease, continue to receive appropriate advice and treatment in line with national service framework standards;
· Maintain the four hour maximum wait in A&E from arrival to admission, transfer or discharge.
3.7.3 Mr Phoenix’s response to the assessment confirms that action is being taken to address all of these, for example:
“Last year our analysis indicated that our eye screening service for people with diabetes was inconsistent. So we appointed one provider for the whole of West Kent from 1 April this year and invested an additional £250,000. GP practices are ensuring their registers for people with diabetes are accurate and up-to-date. Not only do we expect every one of the 23,000 diabetics in West Kent to be offered a check by the end of March – we know that 80% of them have already been offered appointments.
To tackle delayed transfers of care, we have set up pilot projects with the hospital trusts and social services to try different approaches to supporting patients so that they can be discharged from hospital as soon as they are ready to leave. The effect can be seen in the drop in our delayed discharge rate. At Maidstone and Tunbridge Wells NHS Trust, for instance, the rate has dropped from a high of 7.6% a year ago to 2.9% in August 2008, the latest figure available.”
3.8 New National Targets
3.8.1 The Government's new national targets are goals for the entire NHS, which aim to improve the health of the population in England. The Healthcare Commission’s assessment looks at the contribution of individual healthcare organisations in meeting these new national targets.
3.8.2 The “weak” score in relation to new national targets means that the performed below the minimum requirements and the reasonable expectations for the new national targets assessment.
3.8.3 The PCT met 6 of the targets and failed to meet 7. The 7 that it failed to meet or underachieved on were:
· Improve the quality of life and independence of vulnerable older people by increasing the proportion of older people being supported to live in their own home by 2008;
· Increase the participation of problem drug users in drug treatment programmes by 2008; and increase year on year the proportion of users successfully sustaining or completing treatment programmes;
· Reduce the under-18 conception rate by 2010, as part of a broader strategy to improve sexual health;
· Substantially reduce mortality rates by 2010 from suicide and undetermined injury;
· Substantially reduce mortality rates by 2010 from heart disease and stroke and related diseases;
· Ensure that by 2008 nobody waits more than 18 weeks from GP referral to hospital treatment;
· Improve health outcomes for people with long term conditions by offering a personalised care plan for vulnerable people most at risk; and reduce emergency bed days by 2008 through improved care in primary care and community settings for people with long term conditions.
3.9 Information for Patients
3.9.1 The Healthcare Commission looks at how well healthcare organisations perform in a number of different areas of interest to patients and the public. The West Kent PCT scored the following:
· Safety and cleanliness: 11/12
· Waiting to be seen: 3/4
· Keeping the public healthy: 4/7
· Standard of care: 5/7
· Dignity and respect: 8/11
· Good management: 7/16
· Commissioning services: 9/16
· Planning for local improvement: 12/20
4. Annual Health Check for Maidstone and Tunbridge Wells NHS Trust
4.1 The 2007/08 Annual Health Check for the MTW NHS Trust rated its performance as “fair” for use of resources and “weak” for quality of services. It also found that it had not met core standards or existing national targets, and was “weak” in relation to new national targets. Further details about each of these sections are available at paragraphs 4.3 to 4.8.
4.2 The information in the following sections was obtained from the Healthcare Commission website at www.healthcarecommission.org.uk.
4.3 Use of Resources
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4.3.1 The Healthcare Commission’s comment on the NHS Trust’s use of resources was as follows:
“This organisation has at least met the basic requirements in four out of five areas of this assessment and has been given a score of fair for use of resources. Financial reporting was assessed as good and the trust met its financial targets for 2007/2008.”
4.3.2 The Trust’s scores were as follows:
· Financial reporting: 3
· Financial management: 2
· Financial standing: 2
· Internal control: 1
· Value for money: 2
4.4 Quality of Services [see also Section 2.4]
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4.4.1 The trust automatically scored 'weak' for quality of services because it scored 'not met' for both core standards and existing national targets (detailed below).
4.5 Core Standards
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4.5.1 The MTW NHS Trust, in 2007/08, was compliant with 23 core standards and not compliant with 20. However, the Healthcare Commission does list the actions put in place by the MTW NHS Trust to address those standards it was not compliant with and only the following are not currently expected to be compliant:
· C08b – personal development. This was not met as “not all staff have had a personal development plan drawn up in the last 12 months”. A number of actions have been or are being implemented to address this, including the integration of a Personal Development Plan process into the Appraisal process.
· C11b – mandatory training. This was not met as “not all relevant staff have participated in mandatory training in the last 12 months (including refresher courses)”. Steps have been taken to address this and the Training function will monitor compliance and produce quarterly reports.
· C20b – privacy and confidentiality. The assessment notes that “the estate does not promote privacy and dignity and we will not be compliant fully until the PFI build in 2010”. However, a number of actions have been taken to improve patient privacy and dignity, including introducing more single sex washroom facilities to wards, erecting screening between male and female ward areas and widening the gap between beds on the wards by reducing the number of beds on wards.
· C23 – public health cycle. This looks at whether healthcare organisations have systematic and managed disease prevention and health promotion programmes which meet the requirements of the national service frameworks (NSFs) and national plans with particular regard to reducing obesity through action on nutrition and exercise, smoking, substance misuse and sexually transmitted infections. An assessment of the standard for the MTW NHS Trust shows evidence available and gaps in both evidence and compliance.
4.6 Existing National Targets
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4.6.1 The MTW NHS Trust met 5 existing national targets in 2007/08 but did not meet a further 5. The 5 that were not met or were underachieved on were:
· Maintain a maximum wait of 26 weeks for inpatients;
· Deliver a ten percentage point increase per year in the proportion of people suffering from a heart attack who receive thrombolysis within 60 minutes of calling for professional help;
· Every hospital appointment to be booked for the convenience of the patient, making it easier for patients and their GPs to choose a hospital and consultant that best meets their needs. Patients should be able to choose from at least four health care providers for planned hospital care;
· All patients who have operations cancelled for non-clinical reasons to be offered another binding date within 28 days, or the patient’s treatment is to be funded at the time and hospital of the patient’s choice;
· Maintain the four hour maximum wait in A&E from arrival to admission, transfer or discharge.
4.7 New National Targets
How Acute Trusts
Performed: 44.9% Excellent 42.0% Good 10.7% Fair 2.4% Weak MTW NHS Trust 2007/08: “weak” MTW NHS Trust 2006/07: “weak”
4.7.1 The MTW NHS Trust achieved 6 new national targets and either failed or under-achieved on 4 new national targets as follows:
· Reduce health inequalities by 2010;
· Secure sustained national improvements in NHS patient experience by 2008;
· Substantially reduce mortality rates by 2010 from suicide and undetermined injury;
· Ensure that by 2008 nobody waits more than 18 weeks from GP referral to hospital treatment.
4.7.2 The MTW NHS Trust has detailed action plans in place to address new and existing national targets; these can be viewed at http://www.mtw.nhs.uk/about-the-trust/annual-health-check-declaration-action-plan2.asp.
4.8 Information for Patients
4.8.1 The Healthcare Commission looks at how well healthcare organisations perform in a number of different areas of interest to patients and the public. The MTW NHS Trust scored the following:
· Safety and cleanliness: 6/13
· Waiting to be seen: 7/12
· Keeping the public healthy: 4/5
· Standard of care: 5/9
· Dignity and respect: 4/10
· Good management: 10/17
5. Reconfiguration of Services
5.1 On 18 December 2007, the MTW NHS Trust received confirmation from the Secretary of State for Health, following a review by the Independent Reconfiguration Panel, that proposed changes to accident and emergency services at Maidstone and Kent and Sussex Hospitals could go ahead. Under the changes:
· Patients who need emergency inpatient surgical and orthopaedic services in Maidstone and Tunbridge Wells will be taken to Kent & Sussex Hospital.
· Patients in Maidstone and Tunbridge Wells who are waiting for elective (planned) surgical and orthopaedic services will have their operations at Maidstone Hospital.
5.2 The implementation of these changes is subject to a number of conditions, which are attached at Appendix A for information.
5.3 A paper was presented to the Maidstone and Tunbridge Wells NHS Trust Board on 27 August 2008 outlining the implementation of the surgical and orthopaedic reconfiguration plan. This report is attached at Appendix B for information. Following consideration of this report, the Trust Board approved the option presented as Option 2, agreed the proposed ‘go-live’ date, may 2009, and ‘check-date’ of January 2009.
5.4 At the meeting of the External OSC on 25 February 2008, the reconfiguration of services was discussed and the relevant extract from the minutes of the meeting is as follows:
“Mr Phoenix stated that the Independent Reconfiguration Panel (IRP), which had been tasked by the Secretary of State for Health with reviewing the reconfiguration proposals, was a national group of independent clinicians who discussed the proposals in detail with a wide range of people who were both in favour of the proposals and against them. The IRP had come to the conclusion that the reconfiguration was in the best interests of patients, though this was subject to a large number of conditions. Discussions were now being held with the Kent County Council (KCC) NHS Overview and Scrutiny Committee and a number of interested parties, including the local divisions of the British Medical Association, with regard to a timetable for implementation. Clinicians were actively involved in this as it was vital that the correct decisions were made in order for the reconfiguration to work. Mr Douglas clarified that there would still be an Accident and Emergency (A&E) department at Maidstone Hospital and 85% of A&E patients would still be treated there, rather than being moved on to the Kent and Sussex Hospital. Work would need to be carried out to assist patients admitting themselves to hospital to establish whether they needed to go to Maidstone or Kent and Sussex hospital, as only patients requiring emergency surgical and orthopaedic treatment would need to go to the Kent and Sussex. Services would not be changed until this was ready. With regard to transport between the two hospitals, Mr Douglas highlighted that the construction of the Colt’s Hill bypass would be a positive step.
A Councillor asked for clarification on what was meant by “consultant-led” services with regard to the reconfiguration of services. Mr Douglas explained that this meant a consultant would be present in the hospital during normal office hours and would be available on the telephone out of hours. Trained doctors would be available 24 hours a day, and specific specialities would be constantly catered for, for example following the reconfiguration there would be a dedicated trauma team at Kent and Sussex Hospital on a permanent basis. Mr Phoenix highlighted that the Trust’s External Review Group would be looking at detailed staffing proposals at various levels and in a number of specialities to ensure that this was correct for the reconfiguration of services.
A member of the public asked the witnesses whether all orthopaedic surgery would move to the Pembury PFI Hospital when it was built, including elective surgery. Mr Douglas confirmed that all orthopaedic and trauma surgery would be performed at the Pembury PFI Hospital. The short-term plan was to perform elective surgery at Maidstone Hospital due to capacity constraints at the Kent and Sussex Hospital. The Pembury PFI Hospital would have single rooms which were the preferred option for surgical patients as it improved infection control.”
5.5 A key concern of the External OSC when it considered the proposed reconfiguration in 2006-07 was transport between Maidstone and the Kent and Sussex Hospital. The KCC NHS Overview and Scrutiny Committee received an update on travel issues and access to healthcare at its meeting on 17 October 2008. The following is an extract from the report provided to Members of the NHS OSC:
“At a recent meeting between the Chief Executive of the County Council and the two PCTs in Kent, it was agreed to undertake some intensive joint work on health and transport issues of the kind which have featured quite prominently in discussions about both the Maidstone & Tunbridge Wells NHS Hospital Trust's service changes and work to identify the best location for the provision of services in Dover as the Buckland Hospital site and facilities have become unsustainable. The questions being tackled in this strategy development are:-
· are current and planned healthcare facilities in the best location with regard to their accessibility for those requiring access to them (i.e. patients, relatives/friends, staff)?
· how can existing transport infrastructure and facilities, planned/commissioned/provided by various agencies, be more effectively deployed?
· what are the examples of best practice we can import and replicate/adapt for Kent?
This work will build on that already underway in East Kent. Partners are pooling resources to support a project approach – that is to say, task-and-finish.
It is intended to report to the Health Overview and Scrutiny Committee as part of the quality-assurance of the project by Spring 2009.”
6. Pembury Hospital
6.1 The Secretary of State for Health gave final approval for the Pembury Hospital development in March 2008. The hospital will provide a full range of services including planned and emergency surgery, orthopaedics, a women and children’s centre (including maternity and inpatient children’s services), day case theatres and outpatient services.
6.2 The circa £225 million hospital will have 100% single rooms designed to address key issues such as privacy, dignity and infection control.
6.3 Work on the development started in April 2008 and the hospital is expected to open in 2011.
7. Local Involvement Networks (LINks)
7.1 The Local Government and Public Involvement in Health Act 2007 introduced Local Involvement Networks, or LINks. There will be one LINk for the whole of Kent and it will replace existing Patient and Public Involvement Forums. The LINk will collect and represent the views of all of the different groups and people that live in Kent on issues relating to health and social care services. LINks will also have the power to refer issues to Overview and Scrutiny, and to enter and view some health and social care facilities.
7.2 LINks will provide the opportunity for local residents to be directly involved in the monitoring and assessment of local health and social care services, and as membership would be not be drawn from the PCT, NHS Trusts or local authorities, will be entirely independent. The Department of Health is also emphasising the fact that residents do not need to be a member of a LINk to get involved and have their say.
7.3 The most recent newsletter with regard to the Kent LINk is attached at Appendix C. This is for information only – Members are reminded that the establishment of the LINk is the responsibility of Kent County Council, therefore any detailed questions that Members may have on this should be referred to KCC.
[1] Scale: 1 = inadequate performance; 2 = adequate performance; 3 = performing well; 4 = performing strongly.