This Trust provides most of Hillingdon’s NHS hospital services, in one of its two hospitals.· Hillingdon Hospital’s Accident and Emergency Department provides all emergency care, as Mount Vernon does not have an A & E Department, but most of the Trust’s elective surgery is performed at the Mount Vernon Treatment Centre.·
This page will focus on news from Hillingdon Hospital and the Trust’s Board Meetings held in public. News of the Treatment Centre will appear on the Mount Vernon Hospital page.
Monitor targets: The Trust maintained all the Monitor targets in quarter four, including those for clostridium difficile and A&E, and maintained a “green” risk rating for governance and 3 for finance throughout 2012/13.
Infection control: All Trusts are expected to deliver zero MRSA tolerance with targets of O bacteraemias. For 2013-14 the target for clostridium difficile is maximum 14 cases.
Finances: Hillingdon CCG, the Trust’s main commissioner is reducing the Trust’s income by £20m in 2013-14, so the Trust is being expected to provide increased levels of activity for lower income. Intermediate and complex spinal surgery will end in the Trust in July 2013.
The financial impact of the contractual penalty by which the Trust receives only 30% of the tariff income for non-elective admissions above the 2008/09 baseline robbed it of around £2m in 2012-13.
The outcome from 2012-13 was a deficit of £1.9m, as planned. However, the Trust achieved £6.347m of savings in the year, a little above its revised plan for that period, representin 3.4% of its turnover. For the current year it has a target to save £11m.
Treating private patients can be risky. One loss of £77k for an overseas visitor has had to be written off, despite all possible action for its recovery. Non-NHS income accounts for 3% of the Trust’s total income, of which private patient income is a very small proportion. The Trust has no plans to increase such income.
A&E pressures: Despite huge winter pressures, the Trust met the four hour to treatment or discharge target in Quarter 4, unlike eleven other London Trusts which failed to do so. Emergency admissions rose from an average of 273 per week in April 2011 to 293 per week in April 2013. the increasing demand has prevented closure of the winter capacity beds.
London Ambulance Service arrivals: Over the last six months ambulance arrivals have increased by 12% with more seriously ill patients too. Over the early May Bank Holiday weekend 2013 arrivals increased by 70% on the Friday, 20% on Saturday, and 57% on Sunday. New operating procedures have been developed prior to the lat May Bank Holiday weekend and an additional Emergency Nurse Practitioner and a staff grade doctor are working from 1800hours to 0200 hours each day. As a further hazard, from April 1st a new £200 penalty is applied for every ambulance delayed by over 30 minutes in discharging its patients.
Merging of PALS with the Complaints Department: This merger is underway.
Development plans: Planning permission has been granted for the new Emergency Care Acute Medical Unit, subject to conditions. Before any further planning application the Trust must produce an updated Travel Plan, an overarching masterplan for all future phased development including efficiency of water, electrics, energy, landscape, heritage, highways and car parking.
Work on the new fracture clinic and plaster room will be completed before the main works are started in the kitchen area. Work in Lister Ward is expected to start in June 2013. Work on the Urgent Care Centre is expected to start in July, for completion in September. Work on the A&E waiting area and Clinical Decisions Unit is expected to start in July and work on the new corridor to the new building will start in March 2014.
Academic Health Science Partnership: The Trust is a member of the Imperial College Partnership, which has applied to be designatedas the Academic Health Scienc Partnership for North West London.
Review of inpatient deaths in December 2012 to assess impact of weekday v weekend admission: An extensive report was presented to the Board, after extensive investigation. No firm conclusions were possible. Close monitoring will be carried forward.
Care Quality Commission Survey of Adult Inpatients 2012: 354 patients completed the survey, aresponse rate of 43%, below the average 51% rate for all Trusts. The CQC uses 60 questions, in 10 sections. The Trust scored about the same as most other Trusts in all ten sections.
Nursing ratios: In a recent benchmarking exercise, the patient to nurse ratio at the Trust was in line with the average for the compared Trusts.
National staff survey: The Trust was the best performing hospital in London in relation to staff recommending the Trust to friends and family for treatment.Development of a business case for for a skin centre at Mount Vernon: This development is part of the Cancer Strategy. It will bring together clinicians from a number of specialties to deliver NICE approved services, which are expected to attract tertiary referrals from outside of Hillingdon.
Items of special interest from the Board papers
Achievement of Monitor targets in 2012-13: All targets were met, leading to a green governance rating in every quarter of the year, whilst retaining a financial risk rating of three and delivering the planned income and expenditure deficit for the year of £1.8m. The 3.4% efficiency savings of £6.35m were below the original plan by £0.69m, but bettered the re-forecast target of £6.25m for the year. Strenuous infection control led to 23 cases of clostridium difficile, within the target of maximum 24 cases, and there was one case of MRSA bacteraemia, within the target of three.
Hillingdon CCG’ key priorities for 2013-14: Hillingdon Clinical Commissioning Group now commissions local health services, including hospital care, so its priorities impact on all local providers:
- Enabling people to die in their preferred place of death
- Reducing emergency admissions from care homes by 10%
- Reducing by 10% the average length of stay for people aged over 65 admitted as a result of a fall.
Shaping a Healthier Future: CCGs now lead this five year programme but providers must plan ahead towards implementation including capital developments, work force planning, changes to clinical pathways and management of the transition of services between sites, Outline business cases for capital must be completed by December 2013 and full business cases by March 2014. Proposed changes at Ealing Hospital will impact on Hillingdon’s Maternity and Accident and Emergency departments, including staff numbers and skill mix. Some contracts for the Emergency Care Reconfiguration contract for Hillingdon are expected to be signed in May 2013.
The Urgent Care Centre – in the vacated Fracture Clinic, Plaster Room and Minors area – is expected to open in September. The Fracture Clinic and Plaster Room is expected to be operational in a new modular building on the footprint of the old Occupational Health portakabin, by the end of July. Planning permission for further developments will require a masterplan for car parking.
Finance: The Trust continues to maintain its financial risk rating at 3, as required for a Foundation Trust.
Efficiency savings: Year to date there was a shortfall of £530k against plan, 9.5%, with all Divisions significantly underachieving.
Performance: Activity in A&E is greater than last year, leading to a greater number of emergency admissions and January had the highest number of emergency admissions since December 2010. However, despite this increase in activity and the move of Edmunds Ward to the Hillingdon site, bed availability remains strong. Month by month more blue light ambulance patients have arrived – 117 in October up to 149 in January 2013, with an increase too in the degree of illness of the patients arriving. To meet this increased demand staff has been increased too with an extra doctor working 6pm to 2am and an extra nurse working a late and night shift.
The revenue generated by this additional activity was highly suppressed by the national tariff caps linked with readmissions and emergencies. The Trust is currently paid for only a level of re-admissions showing a 27% reduction compared to last year – this cap generated £1.75m of unfunded activity to date. Rather than being reduced, emergency activity has increase by 0.6% so far this year.
Monitor ratings: The Trust maintains its financial risk rating of 3 and its green risk rating for governance - 61% of FTs are similarly rated. Monitor is currently consulting on proposed new rating criteria.
Finance issues: The Audit and Assurance Committee was advised of two debts each over £50k currently with the Trust’s collection agents, which are likely to need to be written off next quarter. £7.1m of non-NHS income comes from rental contracts, overseas visitors, private patients, research etc.
Winter pressures: In preparation for winter pressures, in early January 66% of the Trust’s staff had received the winter ‘flu vaccine, including 72% of the Trust’s nurses and midwives.
Liverpool Care Pathway: This is recognised as a gold standard for patient centred care for dying patients, but poor application has led to media concerns. A review will be chaired by Baroness Julia Neuberger. Since 2006 this Trust has followed the Marie Curie Palliative Care Institute’s guidance on the LCP. It has never received any form of financial incentive for using this pathway.
Retirement of Dr Susan LaBrooy: This was Dr LaBrooy’s last Board Meeting in public. She is leaving the Trust after 27 years service. However she is continuing to work with NHS North West London on its “Shaping a healthier future” project and she has indicated that she would welcome an opportunity to speak to The Community Voice about that work at some point in the months ahead.
Monitor: The Trust’s green rating for governance and three rating for finance have been confirmed by Monitor.
External inspection: The Care Quality Commission undertook an unannounced inspection of Hillingdon Hospital on 5th December. The team visited A&E, maternity, paediatrics, the Emergency Assessment Unit, the Stroke Unit, Beaconsfield East, Hayes, Kennedy and Bevan wards. Verbal feedback was generally positive with praise about nutrition and respect for patients – patients were very positive about their experiences. A written report was expected shortly.
Project 2015 is still at a preliminary stage with discussions underway between the landlords of the site, Hillingdon Hospital NHS FT, and major site tenants, the Mount Vernon Cancer Centre, which is the responsibility of East & North Herts NHS Trust. Both trusts have keen interest in future developments on the site. The current cancer wards are very outmoded and due for replacement, but both trusts are short of cash for an inately expensive project. However, the two trusts are talking their way through the complexities and patients simply wish them success in this very important mission.
“Putting People First”: This initiative, launched by the Trust on 28th November, was attended by Board Members and top management, to emphasise the importance of improving the experience of its patients, particularly the elderly, pregnant mothers, those with dementia and those with long-term conditions. The message, which is expected to cascade from top to bottom of the Trust, holds no surprises, only what patients have always expected – personal care responding to the patient’s needs - not only excellent treatment but also kindness, compassion and good communication.
As part of earlier initiatives the Trust has recently set up a Glaucoma User Forum, a Black Minority Ethnic Age UK Hillingdon Forum, and a Starlight Pantomime to provide a positive hospital experience for oncology children and their families. All these will impact on the experience of patients within the Trust.
Performance: There was a steep climb in the number of admissions in October (the latest data available), with a record 71 admissions against a predicted 52, which led to Churchill and Lister Wards being temporarily re-opened. However, overall occupied bed-days were below that of last year, despite increased volumes of activity. During October there was a 9.3% increase in patients arriving by ambulance, 2253 compared with 2062 last October.
External inspection: The August report of the Emergency Care Intensive Support Team (ECIST), a Dept. of Health team, supported the Rapid Assessment and Triage model currently being rolled out in the Emergency Department which ensures that senior clinical decision makers see patients as soon as possible on their admission. ECIST supported development of frail elderly services in the department as more over 75s have been admitted during the last two years. However it identified opportunities aiming to discharge 65% of non-elective admission within two midnights or less.
Finances: The Trust has maintained its financial risk rating at 3 as required for its foundation trust status. Higher than planned activity, with revenue increase by 4.5% compared with last October, was almost entirely offsetting the Trust’s efficiency savings shortfall. This was achieved with 40 fewer whole time equivalent staff. Year to date there were 127 more births than for the same period last year, an increase of 5.3%. However, the cumulative level of readmissions for the period increased by 3.9%, generating £1.5m of unfunded activity.
Emergency Readmissions: This is a particular issue as there is no payment to the Trust for patients readmitted within 30 days of discharge. Hillingdon Clinical Commissioning Group audited the 59 such patients readmitted by the Trust in July and the Trust audited all 68 such patients. Resultant developments already bear fruit - some indicated below - October readmissions dropped from 13.7% last year to 7.4% in 2012.
- A joint bid to the Integrated Care Pilot to explore early discharge support and a falls prevention service.
- The Leaving Hospital Leaflet now advises call the GP for advice after 24 hours from discharge.
- A&E discharge summaries are being electronically written - easier to read than hand written notes!
- Patients thought to be within the last 12 months of life are being registered as needing special care.
- Joint care plans are being developed for patients discharged after surgery.
- Joint care plans are also being developed for frail elderly patients living independently at home.
Retirement of Medical Director:
Dr. Susan LaBrooy is retiring in December. Dr Richard Grocott-Mason is currently in the process of taking on her role as Medical Director.
The Risk Rating remained at 3, as required by Monitor. Year-to-date actual performance for August was a deficit of £1,292k, which was £180k better than expected at this point in the year, but all Divisions under-delivered against their efficiency savings plans, with a year-to-date shortfall of £219k.
Readmissions increased by 111 spells, an increase of 8.4% compared to last year. However, in an attempt to reduce readmissions, NHS rules base maximum payment for this year's readmissions on 73% of the readmissions last year - any readmissions above that 73% have to be done without payment. So, the actual readmissions this year have obliged the Hillingdon Hospital Trust to provide unfunded work worth £1.2m.
Department of Health Guidance does not expect the commissioner (the Primary Care Trust or the Clinical Commissioning Group) to profit from work being done in hospital without payment - the money saved from non-payment is supposed to be invested in health services in the community. In theory this is sensible, because readmissions to hospital often arise because care in the community is inadequate. However, to date no evidence has been produced to show what has happened to the savings arising from non-payment for Hillingdon Hospital readmissions, and there is no evidence that it has been used to improve local community health services. Sadly, if not ring-fenced, such "savings" can easily get "lost" in the commissioners' other financial problems.
Improving care for dementia patients:
The League of Friends and The Comforts Fund have provided new clocks in a number of wards and public areas which are easy to read and display the date and time. Wards have devised drinking glasses for patients with different needs – green for dementia patients, as green is easy to see – red for patients who need encouragement to drink – weighted cups for patients with Parkinson's Disease