1.1
The Chair welcomed everyone to the meeting and stated it had been
convened to jointly consider the report on financial turnaround for
Barts Health NHS Trust and the consultation on the proposals for
specialist cancer and cardiovascular services in North and East
London and West Essex.
2.Membership of
the Committee
2.1
The Committee noted the updated Membership list for Inner North
East London Joint Health Overview and Scrutiny Committee. It was
noted that Councillor David Edgar had replaced Councillor Lesley
Pavitt from the London Borough of Tower Hamlets.
3.Apologies for
absence and notice of any substitutions
3.1
Apologies for absence were received from Councillor Dr Emma Jones
from the London Borough of Tower Hamlets, Councillor Benzion Papier
from the London Borough of Hackney, and Councillor Ted Sparrowhawk
from the London Borough of Newham.
4.Declarations of
Interest
4.1
There were none.
5.Minutes of the
previous meeting
5.1
The Committee gave consideration to the minutes of the meeting held
on 29 May 2013.
RESOLVED – That the minutes of the meeting of the
Committee held on 29 May 2013 be agreed as a correct record.
6.Actions and
matters arising from the previous meeting
6.1
There was none.
7.Barts Health NHS
Trust - Report on financial turnaround
7.1
The Chairman welcomed the following senior officers from Barts
Health NHS Trust to the meeting:
Mr Peter Morris,
Chief Executive
Mark Cubbon,
Executive Director of
Delivery
Mark Graver, Head
of Stakeholder Relations and Engagement
7.2
At their previous meeting on 29th May 2013, the INEL
JHOSC considered the draft Quality Accounts for Barts Health NHS
Trust. Mr Morris stated that since then the Trust had begun a
financial turnaround programme to improve the quality of patient
care, increase speed of delivery and improve efficiency whilst
delivering cost savings and productivity improvements.
7.3
As the largest NHS Trust in the country the reduction of the
National tariff by 4% would result in a £50m saving to be
made per year for Barts. In addition, a further local target of
£28m needed to be found as transitional funding had been
received previously and would fall away over a 2 year
period.
7.4
Mr Morris outlined a three year plan in place to achieve a
sustainable long term financial position. In 2013/14 the focus was
on stabilising finances via cost reduction and increasing income
through Payment by Results. In 2014/15 Mr Morris stated attention
would shift to address the underlying financial deficit so that in
2015/16 a financial equilibrium could be achieved.
7.5
Mr Morris highlighted the need to change current operational
practices, and advised that this would involve restructuring and
unifying the workforce. A review of management, nursing and
administrative posts within clinical services had followed a
corporate review, and a consultation on staffing levels had been
launched in August 2013 with unions, staff and stakeholders to
ensure proposed structures and processes were fit for purpose.
7.6
The turnaround and change in practices would require continued
support for clinical and corporate functions, along with support
for smaller groups within the organisation in order to utilise
opportunities for improvement and ensure best practice was
shared.
7.7
With regard to income, Mr Morris advised that over the past 12
months they had moved away from block contract payments, and would
operate via Payment by Results so that work undertaken would be
paid for in full. He also stated that income was a significant
consideration in the long term plan.
7.8
Mr Cubbon provided more detail on the process for challenging and
scrutinising decisions and ensuring robust practices.
Recommendations from the National Audit Office had been implemented
to improve quality of care and health and safety: The organisation
was split into a number of divisions and each would have assessment
levels to scrutinise proposed decisions and plans.
7.9
Senior doctors would present to a panel of officers (i.e. from
Finance and HR) on any new plans, giving assurance and taking
questions. The scheme would then be accepted or challenged
accordingly and go on to be presented to the Chief Nurse and
Medical Doctor. The cost implications of each scheme would go to
the Trust Board to undergo a further degree of scrutiny.
7.10
With regard to external involvement in the process, an overview of
each scheme and the process followed would also be presented to NHS
England. An on-going monitoring process would track further
financial opportunities, assess how schemes were impacting patients
and service users, and recognise any risks or emerging
patterns.
7.11
Mr Cubbon acknowledged that this was an intensive workload, but
stated that it was critical in such a large organisation to ensure
opportunities were realised and decisions were robust. The Trust
had received positive feedback concerning this arrangement.
Questions and answers
7.12Councillor Ann Munn opened the questioning by asking
the officers to give more information concerning the financial
predictions for 2014-2016.
7.13
Mr Morris replied that the end of 2015/16 should see the Trust
break even. In 2014/15 the focus would be to reduce and eliminate
the underlying financial deficit, which was in the region of
£50m, in addition to accommodating the step in Private
Finance Initiative (PFI) payments.
7.14Wendy Mead queried the effect taking charge of the
cardiovascular services at St. Bartholomew’s Hospital would
have on PFI payments.
7.15
Mr Morris responded that further to consultation, an application
would be made to make changes to the building and the ground
prepared for the other hospitals, extensively using the St
Bartholomew’s site. With regards to PFI, Mr Morris advised
Members that the extra patient load would result in extra revenue
and that there would be an exercise to determine the cost of
changes
7.16Councillor Ann Munn asked whether the process for
scrutinising decisions would be on-going, and asked for more
information regarding Clinical Academic Group (CAG) specific
schemes.
7.17
Mr Cubbon confirmed that the efficiency process would be on-going,
and that CAG specific schemes were small, local schemes which built
up over time into significant costs.
7.18
Mr Morris added that the numbers concerned were constantly
changing, with new schemes being delivered in addition to existing
ones. As an example, he spoke about increasing the robustness of
theatre scheduling, highlighting that although the target was set
at 65%, the aim was to surpass this in 2014/15.
7.19
Mr Cubbon reported that significant resources were being put into
the restructure of the work force to understand how it is
constructed and that salaries were being paid on an equitable
basis. The forthcoming changes to unify the workforce were expected
to deliver significant savings as well as improving efficiency. Mr
Cubbon stated that £48m of £62m savings for 2013/14 had
been delivered so far, with the rest to be delivered in the next
few months.
7.20The Chairman queried whether Payment by Results would
financially impact CCGs and whether it would be harder to achieve
important outcomes.
7.21
Mr Morris assured Members that the Trust was working closely with
CCGs, tracking economics across the system on a monthly basis to
ensure a sustainable way could be secured to run care pathways. He
added that they were encouraging themselves to do more to reduce
waiting times, treating patients close to home wherever possible
through an integrated care agenda.
7.22With reference to the feedback from staff consultation,
Cllr Akehurst declared a non-pecuniary interest by virtue of being
a member of Unite. He asked whether any lessons had been learned
for future consultations and what steps were in place to increase
morale.
7.23
Mr Morris acknowledged the difficulty in reaching thousands of
people and reducing their stress and anxiety but confirmed that
support arrangements were in place; downgraded staff were protected
against loss of earnings and communication was on-going,
particularly with staff reps.
7.24
With regards to lessons learned, Mr Morris stated that allowing
sufficient time for comments to be submitted and for feedback to be
considered was paramount. Both these timescales had been extended
in the consultation, the latter from one to three weeks, and Mr
Morris reported that a better set of outcomes had been reached as a
result.
7.25Cllr Edgar enquired whether benchmarking would be used
more generally in the future, and whether the recruitment of staff
whilst downsizing the workforce reflected a mismatch of
skills?
7.26
Mr Cubbon responded that as a relatively newly merged organisation
it was necessary to get outside expertise. Organisations and
services of a similar size had been compared nationally, and showed
that the Trust had more staff on higher pay than comparable peers.
This comparison was supplemented with benchmarking which compared
London against the National nursing skill base. Mr Cubbon reported
that staffing levels were not universally reduced, as some areas
were being recruited to.
7.27
Mr Morris advised Members that the benchmarking exercise had been
tailored to suit the organisation’s shape and size which
allowed them to be more confident of the relevance and robustness
of conclusions drawn. He stated that the Trust came close to
benchmarks from Safe Staff Alliance, and had retained a 65:35 mix
of trained-to-untrained staff. He added that the Chief Nurse had
the power to change the staff mix in particular areas, and extra
monitoring and flexibility would ensure shape and number of staff
was fit for purpose.
7.28
Mr Cubbon stated that although recruiting whist downsizing staff
might seem counterintuitive, it was necessary to address the
mismatch of vacant posts and current skill levels. The Trust wanted
to reduce the reliance on temporary staff, with an internal target
of achieving 95% of a workforce of 14,500.
7.29In light of the CQC reports highlighting problems with
staff morale, Cllr Saunders asked how they were being
tackled.
7.30
Mr Morris replied that staffing was an issue in terms of the level
of agency staff and morale. A low appraisal rate had been observed
previously but now a consistent appraisal system was in place,
including team meetings and appraisals which were up to
approximately 90%.
7.31
Mr Morris spoke about an annual opinion staff review and a smaller
monthly survey (of approximately 2000 staff) carried out to gauge
the mood of the organisation. At a request from Councillor
Saunders, Mr Morris confirmed he would be happy to share these with
the JHOSC.
7.32With reference to down-banding, the Chairman queried
how staff members were being redeployed and whether patient
experience had been affected?
7.33
Mr Morris explained that any redeployment depended upon which posts
would be free and the extent to which individuals were willing to
accept posts based elsewhere in the organisation, considering their
personal circumstances.
7.34
In response to the Chairman’s request for figures estimating
redeployment, Mr Morris was not willing to judge what might happen
over the next 18 months but undertook to come back with figures at
a later date.
7.35
Mr Morris informed Members that, as yet, there was no evidence that
redeployment of staff had affected patient experience either
positively or negatively. Changes were still being executed and
monitoring would continue in order to highlight and address any
adverse effect observed.
7.36Wendy Mead asked whether the planned movement of staff
to St Bartholomew’s was part of the redeployment
plans.
7.37
Mr Morris confirmed that the London Trust team would move entirely
to the St Bartholomew’s site but this would not be part of
the redeployment process. With regard to Heart Hospital, work was
underway to establish the required workforce, and more detailed
preparations would begin in summer 2014.
7.38Cllr Paul queried the levels and locations of agency
staff compared with benchmarking, and asked whether there was a
risk map in place to assess issues of quality and safety concerning
temporary staff.
7.39
Mr Morris assured Members that the reliance on temporary staff
would be reduced to more sustainable levels over the next 12
months, but it would take time to iron out the differences in
specific sites. 14 additional staff had been recruited in HR to
manage this.
7.40
Mr Cubbon added that assessment of risk was part of everyday
procedures, and a mitigation plan was in place from Ward level up
to the Board.
7.41With reference to the CQC report concerning Whipps
Cross, Cllr Saunders asked how the issues identified were being
addressed.
7.42
Mr Morris advised Members that numerous housekeeping issues at
Whipps Cross had been identified during the inspection, and now the
Trust were ensuring the correct mechanics were in place to
recognise problems and address them internally. He confirmed that
the maternity services at Whipps Cross were safe, secure and
effective, but recognised that the maternity patient experience
needed to be better. He reported that a culture change within the
service was being embarked upon to improve the service of care.
7.43
In response to a follow up question from Councillor Saunders, Mr
Morris gave more detail as to the changes made to pick up issues in
the future. He stated that a six figure sum had been invested to
fix the maintenance issues identified during the inspection, and
this provided a visible change to drive further improvements. As
other maintenance work was completed, staff were recognising that
things were being fixed whenever they were discovered or reported,
which encouraged better communication to highlight issues.
7.44
The Chair thanked Mr Morris and the officers for taking the time to
attend and answer the Members’ questions.
8.Improving
specialist cancer and cardiovascular services in north and east
London and west Essex - Consultation on case for
change
8.1
The Chair welcomed the following senior officers to the
meeting:
Neil Kennett-Brown,
NHS England
John Hines,
London Cancer
David Fish,
UCL Partners
Muntzer
Mughal, UCL Hospitals/London Cancer
Ben
O’Brien, Barts Health/UCL Partners
Hilary
Ross, UCL Partners
8.2Mr Kennett-Brown thanked the Chairman, and
informed the JHOSC that early engagement to gather feedback on the
proposals for improvements to specialist services showed strong
support. A leaflet and public events campaign had begun on 28
October and would conclude on 4 December.
8.3Mr Mughal, from UCL Hospitals and London Cancer,
outlined the vision for a world class cancer service with an
advanced computer system and the latest treatments. He informed
Members that survival rates and patient experience was poor in this
part of London, which was a major driver to change and strengthen
services. Five centres were proposed for five rare types of cancer:
brain, head and neck, urological (bladder, prostate and kidney),
acute myeloid leukaemia and oesophago-gastric (upper GI). Focus
would be on giving patients access to the best specialist
care and to the latest treatments and clinical trials, improving
patient experience and holistic care, and utilising the research
opportunities.
8.4
Mr O’Brien, from Barts Health and UCL
Partners, spoke about the cardiovascular proposals. Although the
new building was an enabling factor, the high a number of
deaths from cardiovascular illnesses was the real
driver for change. Recent innovations in treatment were now being
offered, but there was still a high number of cancellations due to
organisational issues.
8.5The proposal would see specialist cardiovascular
services currently offered by both University College London
Hospital (UCLH) NHS Foundation Trust and Barts Health NHS Trust
come together in a single centre for excellence at St
Bartholomew’s Hospital in late 2014. Services provided at the
London Chest Hospital and The Heart Hospital would join the new
site, but care would extend beyond the three centres to create an
integrated system felt in the community. Academic forces would be
linked to ultimately create one centre of excellence that could
compete with the world’s academic power houses.
8.6
In closing, Mr Kennett-Brown returned to the feedback from the
on-going engagement exercise. Support had been received from
Clinical Commissioning Groups (CCGs), although the Outer North East
London Joint Health and Scrutiny Overview Committee had voiced
concerns regarding prostate cancer and the future of oesophago-gastric cancer moving from two to one centre. Travel
and access were also important issues, with patients prepared to
travel further for better outcomes and the UCLH committing to
specific access arrangements (i.e. requesting additional disabled
parking bays).
8.7Wendy Mead opened the questioning by
asking officers why UCLH had been selected over Barts to provide
specialist treatment for head and neck cancer, despite the latter
treating more patients in 2012/13?
8.8Mr Fish, from UCL Partners, responded that the lead
for head and neck cancer was an employee from Barts who supported
the selection of UCLH. The hospital could offer strong
infrastructural support, including the UCLA Ear, Nose and Throat
hospital and Postgrad Dental Institute. In addition this was a
nationally funded site to develop proton beam therapy, and a
support was available from neuro-surgery and neuro-oncology
surgery.
8.9Wendy Mead queried the robustness of communications
planned between the various hospitals and sites?
8.10Mr Fish agreed that communications throughout the
NHS were inadequate, but advised that having fewer
specialist sites would reduce communication difficulty as the
complexity of interaction would also be reduced. He assured Members
that investment in informatics could link providers of care across
the partnership; although the current baseline for communications
was low, it was a priority for improvement.
8.11Wendy Mead followed up her question,
querying how reducing the number of sites would improve
patient experience outside of their home territory, which was
largely where problems arose?
8.12Mr O’Brien replied that wider networking
between colleagues would be facilitated to enable better working
relationships and improve communication. Patient pathways would be
integrated the entire way, to ensure patient experience was
consistent and staff communication was continuous.
8.13Mr Hines, from London Cancer, advised Members that
Officers were familiar with the difficulties in moving patients
around the system and that it would be easier with fewer places.
Doctors and specialists would split their time between the centre
and peripheral hospitals to improve communication and patient care,
and investments into informatics would ensure GPs were updated at
every step of a patient’s treatment.
8.14With particular reference to prostate
cancer, the Chairman asked whether it was wise to proceed with the
one centre approach when there were concerns over travelling for
treatment.
8.15Mr Kennet-Brown advised that all proposals were
being evaluated, including single and multi-site options. There was
no evidence to show that the current urology service at Barking,
Havering and Redbridge University Hospitals NHS Trust (BHRT) was poor, but the
aspiration was to become world class, which was why a review was
being carried out. Mr Kennet-Brown informed Members that he would
be sharing the outcomes of this review with the ONEL
JHOSC.
8.16Mr Hines added to this, stating that statistics
showed surgeons who performed complex surgeries on a regular basis
achieved better survival outcomes and the complication rate for
robotic surgery was halved. Cancer survival statistics for UCLH
were comparable to large American centres (which were consistently
successful), and it was therefore justifiable from a clinical
standpoint that operations should be held centrally with high level
surgeons and high level technology. Mr Hines pointed out that
patients in North East London have been travelling to the centre
for treatment since 2005, though patients coming from outer London
would need more consideration.
8.17Councillor Munn asked whether follow up
care for cardiovascular treatments would be carried out
locally.
8.18Mr O’Brien responded that there was a wide
spectrum of cardiovascular diseases; lesser illnesses would be
followed up locally, whilst more complex ones would be treated at
the centre. Ms Ross, from UCL Partners, added that staff would be
rotated between the centre and peripheral hospitals to ensure a
cross site approach for the patient and to establish a robust
relationship with outlying hospitals for discharges.
8.19With regards to consultation on patient
experience, Councillor Paul asked how softer issues would be
addressed in the future.
8.20Mr Kennet-Brown replied that listening to people was
an evaluation criterion, and would be measured through the changes
made as a result of feedback received. The ‘hub and
spokes’ model for the centre allowed for an exchange of ideas
and information to ensure all hospitals benefitted.
8.21Councillor Saunders congratulated
officers on their aspiration to create a world class centre for
excellence, and queried whether this would mean an increase in
private practise and smaller waiting lists?
8.22In response Mr Kennet-Brown reported that an
increase in private patients would not be detrimental as the income
from their treatments would be used to improve the site. He advised
Members that the aim was to attract more people in to using the
centre through achieving an encouraging reputation.
8.23Councillor Edgar asked what the long
term implications were.
8.24Mr Fish stated that the centre would be held to
account permanently by the treatment outcome in the wider
population rather than just the results from inside the hospital.
Ms Ross advised Members that the current cardiovascular provision
was rated excellent, and that twelve Transformation Leaders had
been appointed to bring teams together in order to understand what
is needed from the new service provision.
8.25The Chairman
alloweda question from the
floor: Mr Michael Vidal (Board Member, HealthWatch Hackney)
asked whether there had been discussions about the
proposals with Monitor?
8.26Mr Fish responded that there had been discussions
with the relevant agencies and this included Monitor.
8.27
The Chairman thanked the officers for their report, and it was
agreed that discussions would continue regarding Members’
concerns over the proposals. Mr Kennet-Brown advised the JHOSC that
he planned to meet with the Chairmen of the 3 JHOSCs to share and
discuss outcomes after 29 November 2013.
Councillor Akehurst proposed an amendment to the Committee
Procedure Rules for INEL JOSC. This was seconded by Wendy
Mead.
RESOLVED – That Rule 9.1 be amended to
read:
“The lead administrative and research support will be
provided by the Health Scrutiny Officer from the borough which
holds the Chair with the assistance as required from the officers
of the participating boroughs.”