The Chairman welcomed Seaton Giles from the Care Quality Commission (CQC), and Mark Graver, Kay Riley, Clare Dollery and Pauline Farrell from Barts Health NHS Trust.
Mr Giles gave a short presentation on the inspection of Barts Health NHS Trust. He advised Members that since the appointment of Professor Sir Mike Richards as Chief Inspector of Hospitals new methodology for inspections had been adopted. All hospitals in the UK had been assessed against a number of key indicators which revealed Barts Health to be high risk. It was noted that as this was the first large inspection with the new methodology, no final rating had been given. These would be applied from inspections starting in April 2015.
The inspection asked five questions around eight key areas and an extensive consultation fed into the inspection plan. A large team undertook announced and unannounced visits, and was compiled from a broad range of people to ensure depth and breadth of information. Listening events were held for each named site and Quality Summits were held to discuss how to move forward. Mr Giles briefly summarised three sites where areas for improvements had been found: Newham Hospital, Royal London and Whipps Cross. As well as areas for action, Mr Giles also highlighted the examples of good or outstanding practice for each.
Overall, Members noted that Barts Health provided very good services but there were issues that needed to be addressed. Mr Giles reported that it was early days for a combined Trust and the CQC recognised the scale of the challenges associated with reconciling different cultures and the additional financial pressure. He reported that there was a clear strategy and cohesive leadership, but also a lack of connection between the Executive Board and frontline staff.
Mr Giles advised Members that the Trust were now implementing the action plan, with Clinical Commissioning Groups and Trust Development Authority (TDA) monitoring ongoing performance. The CQC would maintain and ongoing dialogue with the Trust, and there would also be follow up inspections in due course.
The Chief Nurse at Barts Health was invited by the Chairman to respond. She replied that the Trust had welcomed the inspection, and that the robust and well-informed results had been beneficial. The outcome had been balanced and all of the issues raised were already known in some way to the Trust. There had been positive areas of work identified on every site, which had been a boost for staff morale and drew focus for further improvements.
Councillor Ben Hayhurst asked for the CQC to include a contents page for future reports of this size.
Councillor Hayhurst asked for more detail concerning unannounced inspections, and queried how serious the problem was?
Mr Giles responded that the Trust was informed in advance of the inspection as some of the data collection was carried out prior to the inspection itself, but that unannounced visits were less structured. The Trust were not informed of where exactly the inspection team would be visiting, nor how long they would stay, as this was decided by the feedback being received from staff and patients.
With regards to the issue of bullying, Mr Giles advised Members that this term was used in a broad sense and was indicative of staff feeling inhibited, unable to raise concerns, and that their concerns went unheard. In a follow up question Councillor Ann Munn questioned how staff were asked about bullying? Mr Giles replied that they weren’t; it had been an issue raised by staff themselves.
Councillor Luke Akehurst asked whether the inspection had determined how pervasive the problem was, i.e. was it institutional, a lack of positive management process, or lack of communication?
Mr Giles responded that a range of factors had been identified. In addition to institutional problems, incidents of particular individuals undertaking bullying behaviour had also been reported.
In a follow up question, Councillor Rachael Saunders asked whether instances of bullying were connected to the visibility of and confidence in senior leadership.
Chief Nurse Ms Riley at Barts Health responded that the Trust was aware of the problem but hadn’t appreciated the full scale of it. She advised Members that issues concerning visibility of leadership and trust in senior staff were unsurprising owing to the lack of stability of staff in the past. The Trust was looking to do more diagnostics and work was in place to ensure staff could speak freely in open meetings and in confidence. Ms Riley also reported that the Trust intended to look at and learn from other large organisations.
Councillor Hayhurst returned to the issue of management visibility, and queried why initiatives started two years ago, such as First Friday, were still not well known.
Ms Riley reported that Clinical Fridays, where senior management would visit and to review a range of issues and liaise with frontline staff, were an embedded and well-known practice. With regard to First Fridays, Clinical Advisory Groups (CAGs) had been given freedom to implement and organise them in the past, which had failed. Now the Trust were working with CAGs to ensure a more structured approach was in place.
Councillor Terrance Paul asked whether a rating would be given for the Trust, either now or retrospectively.
Mr Giles responded that the inspection was part of a pilot and that as the methodology was untested and still being refined the CQC would not be giving a rating for this inspection, either now or retrospectively. Instead the Commission would re-inspect during 2015 and give ratings for individual services and sites.
In response to a series of follow up questions from Councillor Paul, Mr Giles advised Members that the report from this inspection was very detailed and readers could draw their own conclusions as to a final rating.
With regard to impact on quality of care, Councillor Ben Hayhurst questioned whether use of bank and agency staff was being monitored and how it was being addressed?
Ms Riley reported that there was a drive to reach 95% recruitment underway; Associate Director of Human Resources Ms Pauline Farrell added that current levels were at 90.5% but the Trust was aiming to reach 95% by June. Ms Farrell reported that the bank was generally made up of existing staff members but agency staff would not necessarily be familiar with processes, and their use was being reduced. The recruitment timescale had been reduced to eight weeks, and it was hoped this could be improved to six.
In a follow up question Councillor Hayhurst asked whether there were areas with more reliance on agency and bank staff. Ms Riley responded that there were pockets around specialist critical care which were difficult to recruit to nationally. At the request of Members, Barts Trust undertook to report back on the three departments with the highest number of agency staff for February and at the time of the next INEL JHOSC meeting.
Councillor Rachael Saunders asked for more detail on the number of vacancies, and asked how the Trust were addressing ill-health as a result of unemployment in the local community?
Ms Farrell advised Members that staff turnover was approximately 11-12% and that there were hundreds of vacancies each month. This was being addressed through the drive to 95% recruitment and by monitoring the number of offer letters and approvals for vacancies made each week against a target of 140 offers being made per month.
With regards to local employment Ms Farrell reported that a group had been set up which aimed to bring in local people and giving them access to work. Recruitment drives, apprenticeships and training and development pathways were in place to improve the health of the population through employment.
Councillor Rachael Saunders asked a specific question around patients’ meal times at Royal London, and Dhruv Patel queried why the food at Barts Hospital had been worse than elsewhere.
Ms Riley responded that mealtimes were being protected at Royal London and visiting hours revised. She also reported that volunteers were being recruited currently to assist with mealtimes. With regards to Barts Hospital, Ms Riley advised that the Trust held several different catering contracts as a result of the merge, which would be addressed as they came up for renewal. A change in food provision on the wards at Barts had been implemented straight away, and Members noted that the Trust were about to re-audit the service.
Councillor Terrance Paul returned to the issue of bullying, and asked what was being done to challenge the culture of senior managers and whether there would be any impact on their future employment.
Ms Riley replied that the cultural issues were a hangover from the Legacy Trusts and had been compounded by the merge. Conversations were ongoing around challenging senior leadership and to diagnose problems, though it was assured that any individual bullies would be found and asked to leave.
With regards to the impact on future employment, Ms Farrell responded that a new appraisal process was being developed to link values and performance, which would highlight any issues and affect staff progression. She also advised Members that the Trust were looking to bringing in an external expert to advise on how to identify and resolve the reasons for staff feeling bullied or ill-treated.
Dhruv Patel asked for a general update as to the financial turnaround, and queried whether there had been an impact as a result of recruitment?
Ms Riley replied that the financial position had improved significantly as a result of income levels and other work streams, and reported that recruitment was being made to agreed establishments and as such had not created any issues.
Councillor Ann Munn queried the level of consultant cover in relation to support and visibility of staff.
Clinical Director of the Heart Hospital at UCL Hospitals and Medical Director for Informatics and Governance Clare Dollery reported that some departments had better cover and visibility than others, and this was currently being reviewed. She advised that it related to how people were organised rather than just staff numbers.
In a follow up question, Councillor Hayhurst asked whether the bullying culture extended to junior doctors feeling inhibited to ask for additional support and to what extent was there monitoring of calls to on-duty consultants?
Ms Dollery responded that there was no formal monitoring system of the number of calls. Support was expected and there would be more questions raised over junior doctors not asking for support. She advised Members that all medical staff had 360 degree feedback which was looked at in detail before the staff member was revalidated.
The Chairman thanked the CQC and Barts Health Trust officers for attending and answering questions.