During 2011 Central & North West London Foundation Trust moved its headquarters from Mornington Crescent to a building near Warren Street Underground Station. This serves as the hub from which over 3,000 staff are controlled. Originally the Trust provided only mental health services but it did so for a large swathe of North West and Central London, including Hillingdon and Harrow. It provides inpatient services on the Hillingdon Hospital site. In 2010 it branched out into provision of community health services. responding to the NHS requirement that Primary Care Trusts must no longer both commission and provide services. Hillingdon Community Health amalgamated with CNWL in early 2011 and subsequently CNWL also became responsible for community health services in Camden.
This page will contain items related to CNWL Board meetings and mental health services. Items related to Hillingdon's NHS community services will be shown on our Community Health Services page.
Improvement in Hillingdon performance: The Director of Strategy and Performance reported that, after previous concern about Hillingdon services, there had been recent improvement and it was confidently expected that services would be back on track within two to three months. In answer to a question during public question-time, it was confirmed that Hillingdon Clinical Commissioning Group has begun to improve its allocation of funding for mental health, which has allowed improvements in the services that CNWL provide and it is believed that further improvements in funding will be likely in the years ahead.
Mental Health Crisis Line: The introduction of a single point of access telephone line had proved very popular, with double the number of calls expected.
Use of agency staff: From September agency staff will only be employed if two executive directors agree, which it is hoped will have significant impact. The use of bank staff has increased and this is expected to continue.
Finance: The Trust is obliged to save £25m per year in the years ahead, which is a big pressure on its options and activities. Its current forecast for year end is a deficit of £1.03m, after receipt of an expected allocation from the Sustainability and Transformation Fund. There was much Board discussion confirming that the Trust does not see itself as one that tolerates deficits, although they are now common in the NHS.
Restraint: This issue led to considerable discussion. The Trust does not use restraints, unlike some of its continental colleagues. Unfortunately sometimes physical restraint is necessary in the best interest of the patient, but this is always a last resort, when other options have failed.
Bed pressure: The trust has recently faced great pressure on its beds after a quieter period.
Children looked after: CNWL provides this service for Harrow, Hillingdon, Camden and Milton Keynes. For Harrow, this is a new service. In Hillingdon the CLA team has saved Hillingdon CCG £42,099 by bringing back into Hillingdon children previously placed out of borough. Both Harrow and Hillingdon CLA teams operate from the Westmead Clinic in Hillingdon.
Serious incidents: The Quarter 1 Report for 2016-17 had 4.689 reports of incidents, showing a positive reporting culture within the Trust, but 94% resulted either in no harm or low harm, with only 5% rated as of moderate severity. Learning from incidents is integral to improving patient safety and patient experience across the Trust. There is also work with other trusts to share benchmarking information.
Deaths at Woodhill Prison: Over the last four years there has been a general increase in deaths in prison. CNWL provides services in Woodhill Prison where there have been 17 deaths since 2013, including a number of suicides which has caused concern in the Trust. A number of remedial actions are underway.
3. Community Health services: These services achieved all relevant NHSI Indicators in May 2016. All three community health services provided by the Trust have consistently achieved all targets in the last four months.
- A large number of in-patient admissions over the period
- A rise in the acuity of patients admitted
- Implementation of the Smoke Free Policy, which has generated additional challenges for staff working to support patients experiencing this policy for the first time.
CNWL’s system of medical appraisal covers all consultants, staff and associate specialist doctors. Revalidation operates on a five year cycle, with a completely separate revalidation process for trainees. Appraisal is based on a standard document produced by NHS England. Each doctor should have at least two different appraisers during the five year cycle. Appraisers, usually from the same Borough or service, are expected to have undertaken special training. The Trust makes quarterly and annual returns to NHS England.
6. Legal claims against the Trust: There has been a slight rise in the number of claims received in year. The majority of clinical claims are from mental health services, although there has been a rise in the number received from prison services. Claims arising from assaults to staff continue to be a theme; it is unclear whether further training of staff in therapeutic interventions has yet had an impact. Compared with national and regional levels the Trust is not an outlier in the number of claims reported – this is particularly positive as the national figures are not adjusted for size of Trust. The Trust is on a comparable level with similar Trust types for psychiatry / mental health claims.
The report below provides items of interest from the papers, not a summary of the meeting.
1. Appointment of new Medical Director:
Following the retirement of Dr Alex Lewis, Dr Cornelius Kelly has been appointed as Medical Director.
2. Hillingdon Mental Health:
Monitor targets were not met by Hillingdon Mental Health in March 2016, and complaints, staff sickness and staff vacancy rates were all high.
In contrast Harrow Mental Health and Hillingdon Community Services achieved at least 75% of Monitor indicators.
3. Hillingdon Community Health Underperformance:
For the second consecutive month the target was not reached for “District Nursing Referrals contacted within timescale”, which was attributed to data quality issues, which is being closely monitored.
4. Staff Vacancy rates:
In February Harrow Mental Health had a vacancy rate of 21.12% and a turnover rate of 16.6%.
Hillingdon Mental Health had 20.68% vacancy and 18.7% turnover rates.
However, Brent Mental Health rates were vacancy 28.49% and turnover 23.8%.
2015-16 ended with books balanced, but only because property was sold.
The current year will be financially challenging with a need to reduce spending on agency staff.
All contracts for 2016-17 have been agreed except for North West London, where negotiations continue and formal arbitration is likely to be avoided.
6. Care Quality Commission compliance:
All the CQC’s “Must Do” requirements have been met. The “Should Do” recommendations are in progress.
7. Friends and Family Test:
The Trust’s response rate needs to be improved. However, of the 1104 patients who responded in Quarter 4 of 2015-16, 93% reported that they would be extremely likely or likely to recommend CNWL services to family and friends. Future targets are to achieve response rates of 4% by Quarter 3 and 6% by Quarter 4.
The Trust had no cases of MRSA bacteraemias in Quarter 4 of 2015-16. The Trust’s two cases of clostridium difficile were deemed unavoidable.
Targets: The new target “Early intervention in psychosis”, for 50% of patients to wait less than two weeks for intervention, expects compliance by 31st March 2016.
The referral to treatment waiting time target was reached in Hillingdon in January for the second consecutive month and Hillingdon is expected to achieve this target for the quarter too.
Workforce: The high vacancy rate and turnover is impacting on the quality of care and services and the significant use of agency staff is expensive.
Encouraging recruitment fairs have been held in London and Milton Keynes. A workforce strategy is being developed, which will come to the Board in April 2016.
The difference in quality of experience for patients looked after by permanent rather than agency staff was evident in a recent review. In common with other London NHS trusts CNWL faces recruitment challenges, particularly in offender care. The focus on reducing agency use is continuing.
Care Quality Commission inspection: Good progress is being made against the 24 action areas identified by the CQC inspection. All divisions are compliant with the “must do” actions and 72% of “should do” actions were completed in January 2016.
Finance: The “bottom line” position at the end of January was a deficit of £3.53m, which factored in £2.15m profit from sale of property. Further property sales are expected in year.
In January Hillingdon Mental Health was £634k overspent year to date, largely due to its high vacancy rate and consequent agency spend. Harrow was overspent by £1.3m primarily due to failure of its cost improvement programme and its levels of agency spend, plus placements being insufficiently funded in the agreed contract value.
North West London’s Mental Health contract for 2016/17: This contract covers five London Boroughs including Harrow and Hillingdon. CNWL is very concerned about this contract, which is expected to go to arbitration, as there is a big gap between the terms of the contract and the agreed strategy for 24/7 services which CNWL endorses and does its best to implement, but CNWL cannot provide services for which it is unpaid.
Hillingdon’s funding of mental health services: Recent increases in Hillingdon funding have been better than some other Boroughs, but Hillingdon’s mental health services remain poorly resourced in comparison with other areas.
Deaths in prison: The Chief Executive, Claire Murdoch, reported concern about these deaths and warned that she would raise these concerns in the private Part II of the Board meeting. She noted that prisoners are locked in their cells from Friday afternoon until Monday morning, which Board Members appeared to find disturbing.
Public Health: Harrow is significantly worse than the English average for diabetes, TB, child obesity and adult physical activity. Hillingdon is worse for children in poverty, homelessness, violent crime, diabetes, TB, and acute sexually transmitted infections.
The Hillingdon Service User and Carer Strategy Meeting: The six weekly meetings are well attended by users and carers. The service user Co-Chairs meet with the Borough Director and service managers to raise concerns. Members produce information leaflets and plan to produce a magazine for mental health service users.
Hillingdon Community Health: Patients continue to report an excellent service in the Hawthorne Intermediate Care Unit on the Hillingdon Hospital site. The Bladder and Bowel Service received high satisfaction rates from surveyed patients.
The report below provides only items of particular interest from the papers, not a summary of the meeting.
- 1. Hillingdon and Harrow Mental Health services causing concern: Hillingdon Mental Health services are one of three areas causing concern due to underperformance against Monitor indicators - but the number of patients involved was very small. In addition Hillingdon had high sickness rate of 19.93% and a high staff turnover rate of 21.1%. Hillingdon Community Services performance declined in Quarter 3. Harrow Mental Health Services did not achieve delayed transfer of care due to delay in acquiring care home placements for patients.
- 2. Finance: The Trust expects to be behind plan at year end but it hopes to maintain its Monitor rating of 3. Pay spend is above target compared to plan as submitted to Monitor. But the underachieved pay savings are partly being mitigated by a large number of vacancies being held and not covered by agency. New contracts and additional investments have led to increased expenditure.
Harrow was overspent by £184k in December and £1.15year to date, partially due to levels of agency spend on inpatient units
Hillingdon Mental Health was overspent in December by £183k in month, £488 year to date. Hillingdon continued to have a large savings gap, £620k to date. The service has a high vacancy rate with corresponding agency spend.
- 3. Staff numbers: These continue to fall as permanent staff are not being replaced due to pending redesign changes. Agency spend in December was £2.76m, the highest to date this financial year.
- 4. Bed occupancy: There has been improvement in bed occupancy in Hillingdon over the period February 2015 (130%) to December 2015 (100%). In Harrow there has been a small increase, from 100% to 103%. Bed occupancy continues to be rigorously monitored at local level daily and in three times weekly Bed Management Meetings. Since February 2015 out of Area Placements have been used in exceptional circumstances, using both other NHS providers and the private sector, but no patients are discharged directly to the community from those sites. Safe follow up care is provided by discharge back only to the patient’s local Home Treatment Team.
- 5. “Hello My Name is” campaign: This campaign asks NHS staff always to introduce themselves to patients before delivering care.
In August the Harrow mental health team received the highest number of complaints in the Trust, but that team achieved all Monitor indicators and almost all the internal priority indicators, so there was no obvious correlation between complaints and the service provided generally.
2. Hillingdon staff issues:
The combination of staff sickness and turnover rates is thought possibly to be a factor in non-achievement of Monitor and CQC targets by the Hillingdon mental health team, but delayed transfer of care for patients ready for discharge was due to shortage of available placements. However, community services in Hillingdon are doing well with staff satisfaction rates the highest in the Trust.
3. Children’s services:
Hillingdon is one of the three areas where CNWL provides children’s services. These services are universal and are offered to every child living or at school in the Borough, providing a public health service of prevention and targeted early intervention as well as specialist support for vulnerable children.
Commissioning for health visiting, for children 0 to 5 years, moved to local authority public health on 1st October 2015. School nursing moved two years ago.
The CQC inspection of February 2015 rated CNWL’s community children’s services as Good.
There has been a recent announcement that non NHS funding of public health will face further cuts of £200m across England over the next three years, which could impact on children’s services.
4. General factors for Hillingdon’s children:
There are about 75,000 Hillingdon children, 59.4% from minority ethnic groups. Their health and wellbeing is mixed in comparison with the average for England. Their infant and child mortality is similar to the England average, but the percentage living in poverty is higher than average, as is their family homelessness. Obesity is average, but a lower than average proportion is judged to have achieved a good level of development.
The forecast has improved since last month and a surplus of around £330k is now expected, about half what was planned, but that will depend on expected property sales. The Trust expects to maintain its risk rating of 3.
6. CNWL’s compliance with Care Quality Commission’s inspection findings:
The Trust is working towards total compliance.
- Care Quality Commission compliance: Following the CQC inspection the Trust had 24 areas of non-compliance. The Trust now declares itself compliant with 11 of these issues and work on the remaining 13 areas is in progress with the intention of being fully compliant by the end of December 2015 at the very latest.
- NW London Clinical Commissioning Groups expand adult mental health crisis teams: It was announced today that these CCGs are investing £1.9m a year to expand these teams. The Trust will use the investment for new Home Treatment Rapid Response Teams which will deliver a 24 hour, 7 day a week rapid response function in the NW London boroughs, including Harrow and Hillingdon, for urgent and emergency referrals into adult secondary care mental health services. The new teams are planned to start in November.
- Northwick Park Hospital’s Mental Health Assessment Lounge: Brent and Harrow CCGs have confirmed continued investment in this lounge, which started as a pilot project. Both patients and local GPs rate it as successful in providing a secure environment for mental health patients to be assessed away from the main Accident & Emergency environment.
- Medium and low security beds: Lack of such beds is problematic across London and the country. Last week there were no such vacant beds in either the NHS or private sector in England. Prisoners could not be moved out of prisons into more appropriate care.
- Stopping patients smoking: There is no smoking in any CNWL wards, but in some places patients have been able to smoke in the grounds. Making CNWL premises totally smoking free has proved very difficult and has led to problems in restraining patients, particularly prisoners. It was agreed at today’s meeting that more restraint training is required.
- Finance: At the six month point in the NHS year a number of London NHS Trusts are reporting huge deficits. Stringent national guidance is expected to tackle this serious problem. However, this Trust expects to achieve its end of year financial target, aided by its planned disposal of property.
- Forward planning in Harrow and Hillingdon: The possibility of a new sustainable strategy is being explored with the aim of providing a five year plan for mental health services, which would avoid the current postcode lottery. Such a plan must be affordable. It is envisaged as improving self-help, richer community provision and demedicalisation of some conditions.
- Foreign nationals in CNWL beds: There are usually around 22 such patients, but last week there were 30, which was challenging.
- Asylum seeking children in Hillingdon: Some of these children have been trafficked, suffering trauma of many kinds, in addition to language problems. Their needs are complex. Staffing shortages have been experienced in all three of the Trust’s teams for Looked After Children (LAC). The teams are working to tackle child sexual exploitation, teenage pregnancy, substance use problems and lack of emotional well being. CNWL won the contract for LAC in Harrow at the end of 2014/15.
- 1. Care Quality Commission Inspection Compliance Report: Following the inspection in January / February of eight sites and fourteen wards, the Trust received an overall rating of “requires improvement”, but was awarded an “outstanding” rating for sexual health services and for caring across the whole trust. The Trust is now working towards full compliance with the CQC outcomes which will be completed within six months, but most factors will be completed much sooner.
- 2. North West London contract: Agreement has been reached in principle for this contract, but it has not yet been signed. Agreement was reached after Commissioners offered a further £2m as bridge funding for one year which was very welcome. However, it was noted that Hillingdon’s historic poor funding of mental health is not improved in the proposals for the new contract.
- 3. Finance: At the end of the first Quarter, despite some sale of property, the Trust had a deficit of £350k compared with a plan of a surplus of £3,520k. It was noted that using the sale of property to balance the financial position will have an adverse long-term effect on the Trust’s estate and that as soon as possible the Trust should aim to balance the Income and Expenditure account so that it can utilise property sales for reinvestment in the Trust’s remaining estate and future delivery options. Also, a risk was noted of £70k with respect to overseas income.
The Trust’s cash position is likely to be particularly tight in September and October when the Trust’s dividend payments to the Treasury are due. As well as controlling expenditure, there is work on maximising income, including chasing debt payments.
There was concern that the recently announced reduction of £200m to local authority public health budgets could have a significant effect on the Trust. Local authorities have already reduced the financial envelopes of contracts put out to tender and there is concern about the funding of the health visiting service when it transfers to local authority control in the autumn, which will be closely monitored.
- 4. Report on Performance and Quality for May 2015: The Trust was compliant with all Monitor requirements. Good performance has been consistent in all Community Health Services and Sexual Health Services.
- 5. Staff sickness rates: Latest available data was for April when the sickness rate was 3.59% across the Trust. Hillingdon Mental Health sickness rate for February was 4.56%, for March 4.66% and for April 4.94%, higher in each month than for other sectors except for the Addictions Service which had the highest rate in each of those months .
- 6. Complaints: The CQC reported that verbal complaints were not being logged, which is borne out by low reporting of PALS with the exception of Hillingdon. This is partly because the service is being phased out and replaced by the new patient support service, that requires any member of staff who receives feedback to initiate action and to log all complaints, concerns and compliments on the Datix web.