Agenda item

Representatives of NTHFT will be in attendance in order to outline performance against the Trust’s quality priorities for 2022-2023 and inform the Committee of the emerging priorities for the next year.

Representatives of North Tees and Hartlepool NHS Foundation Trust (NTHFT) were in attendance to provide their annual presentation to the Committee on the Trust’s Quality Account.  Led by the Head of Performance and Business Intelligence and supported by the Associate Director of Nursing, Effectiveness and Clinical Standards, highlights and developments in relation to the Trust’s performance over the course of 2022-2023 were outlined as follows:

 

•         Quality Account Priorities: Members were reminded of the three key NHS priorities regarding quality, namely ‘Patient Safety’, ‘Effectiveness of Care’, and ‘Patient Experience’.  Within these three main categories, NTHFT had several further Quality Account priorities for 2022-2023 (most had rolled over during the last few years), all of which would be detailed in the final published document.  These included:

 

Patient Safety

 

•         Mortality: Compared to the same timescale for 2020-2021 (December to November), the 2021-2022 measure for in-hospital mortalities (Hospital Standardised Mortality Ratio (HSMR)) had increased.  However, in-hospital deaths plus those up to 30 days post-acute Trust discharge (Summary level Hospital Mortality Indicator (SHMI)) had slightly decreased in 2021-2022 compared to 2020-2021 (reporting period: September to August).  The Committee was reminded that COVID-19 activity was not included in the SHMI measure as pandemics were classed as anomalies and would skew the data due to a lack of historical comparison.

 

As had been reported for a number of years now, NTHFT once again performed very well in comparison to other Trusts across the region, and the country, in terms of HSMR and SHMI.  Historically, this was not always the case, though the underlying reasons for previously higher rates was principally due to not capturing how poorly patients were – this resulted in significant changes in how the Trust operated (including strengthening documentation and embracing technology).

 

The Trust’s raw mortality (people dying in hospital – includes COVID deaths) data continued to be fairly consistent, though the COVID-impacted spikes in April 2020 (initial emergence) and December 2020 / January 2021 were acknowledged.

 

Reflecting on the HSMR and SHMI indicator charts for the region, the Committee noted the differences between NTHFT and South Tees Hospitals NHS Foundation Trust (STHFT).  As was often the case within the NHS, the two Trusts did not share many compatible platforms, though did work together to try to join-up systems where possible and appropriate.  Officers also confirmed that mortality indicators could be broken down further (i.e. rates for different age groups) if required.

 

•         Dementia: The increasing trend in patients admitted with a dementia / delirium diagnosis was being maintained, with a slight rise in 2022-2023 (April to December 2022) cases compared to the same period in 2021-2022.  As well as the inpatient care given to those with these conditions, the NTHFT Frailty Team also provided support to people in their own home and helped prevent admission to hospital.  The Trust’s excellent discharge team also plays a significant role in supporting those with dementia / delirium, and the NTHFT pathway for identifying and recording this condition remained robust.

 

In light of the rising number of dementia / delirium cases being seen by NTHFT, the Committee asked if the Trust felt equipped with the required resources to manage this increasing demand.  Officers outlined the use of enhanced care workers to ensure patients were assisted individually, the development of staff skills for those who work on wards with higher levels of dementia / delirium patients, and the community care it provides (unless more specialised support was required in a nursing home).

 

Following-up on this, Members asked if the temporary lockdown of care homes as a result of the COVID-19 pandemic had impacted upon the ability to support those with dementia.  In response, NTHFT highlighted the links with local partners and care home providers, as well as the work to make people feel supported whether they be in hospital, in care, or at home.

 

With reference to a recent update in relation to a previous Committee review of Care Homes for Older People, Members drew attention to challenges regarding Tees, Esk and Wear Valleys NHS Foundation Trust (TEWV) and their ability to support Stockton-on-Tees Borough Council (SBC) with dementia training due to staffing limitations.  NTHFT noted their own Dementia Specialist Nurse who is used to supplement the additional support provided by TEWV, and the multi-disciplinary team (MDT) work around dementia which establishes what actions are already in place for a patient with this condition.  The NTHFT-TEWV partnership had worked very well and was making a difference, with relatives reporting that they really value this multi-Trust approach.

 

•         Infection Control – C diff: Positive performance for the two Clostridium difficile (C Difficile) measures, one which involves cases that are detected in the hospital two or more days after admission (Hospital onset healthcare associated (HOHA)), and the other which refers to cases that occur in the community, or within two days of admission, when the patient has been an inpatient in the Trust reporting the case in the previous four weeks (Community onset healthcare associated (COHA)) – both saw reductions for 2022-2023 when compared to the same period (April to January) in 2021-2022, and were also below the national average.  Further context around these indicators would be available in the Trust’s draft Quality Account document which would be circulated in the coming weeks.

 

•         Infection Control: All-but-one of the recorded infection types had seen increases in the number of cases for 2022-2023 compared to the same period (April to January) for 2021-2022.  Methicillin-Sensitive Staphylococcus Aureus (MSSA) (from 20 to 33 (up 65%)) and Klebsiella species (Kleb sp) bacteraemia (from 14 to 22 (up 57%)) had the most significant rises, with Escherichia coli (E.coli) cases increasing from 61 to 70 (up 15%).  On a more positive note, catheter-associated urinary tract infections (CAUTI) had reduced by 21% (from 227 to 180).

 

NTHFT representatives stated that all Trusts across the region were experiencing increases in healthcare-associated infections, though NTHFT continued to perform well in comparison to others, and a forthcoming campaign regarding hand hygiene would hopefully further contribute to minimising future cases.  The rise in people requiring complex surgery, on antibiotics, and / or higher levels of patient acuity meant that individuals could be picking-up infections more easily.

 

In response to a Member query, it was confirmed that NTHFT did have a Urologist (who worked in partnership with STHFT) and daytime urology cover was in place.  The Trust had also invested in Advanced Practitioners who had been in post for a couple of years now.

 

•         COVID-19 Infections: The number of COVID-19-positive patients in NTHFT hospitals had declined in the past year – in mid-January 2022, this figure stood at 121, then dropped into the 80s in April and July 2022, before lowering further to 30 at the end of January 2023 (as of this meeting, the total was 17).  Treatment of patients with COVID-19 in the Intensive Therapy Unit (ITU) was now rare, and identification of the virus had usually become an incidental find as testing was no longer routine.

 

Members reflected on their own personal experience of receiving high quality care from NTHFT when being treated for COVID-19 and spoke of their continuing efforts to encourage the BAME community to get vaccinated.  The Committee also reiterated its wish to learn more about the Trust’s long-COVID clinic (a request made during the presentation on the previous year’s Quality Account in March 2022) – NTHFT representatives agreed to liaise with colleagues and forward information.

 

•         2022-2023 Flu Cases: New graphic to emphasise the pressures experienced by NTHFT regarding flu towards the end of 2022 and start of 2023.  27 December 2022 was the day with the highest number of flu admissions (37) – on the following day (28 December 2022), nine patients were being treated in ITU with flu.  This was a tough period for the Trust, though the higher-than-usual number of cases during this time may have been as a result of increased testing.

 

The Committee asked if the Trust linked-in with GPs regarding flu prevalence but heard that it only became aware of a case once a patient came through a NTHFT entry-point.  Members were also keen to know about the Trust’s experience of Strep A, a condition which gained national media coverage in late-2022 / early-2023.  It was stated that Strep A data did not have to be submitted as part of nationally returned statistics and that it was usual to get some cases during the year.  Advice was provided where appropriate.

 

Effectiveness of Care

 

•         Emergency Activity: Not normally included in this presentation, but incorporated on this occasion to highlight the significant increase (as at December 2022, and as predicted ahead of the end of the 2022-2023 municipal year) in emergency activity experienced by NTHFT.  Overall, attendances to A&E and Urgent Care were up 45% when comparing December 2022 with December 2021.

 

In light of these increased pressures, the Committee expressed concern about the unabating stress on staff and queried if NTHFT had bolstered its resources in this service area.  Trust representatives assured Members that a winter plan was always prepared and actioned, with extra beds made available for the anticipated rise in demand.  Extra staffing support also formed part of the plan, and expert practitioners further assisted emergency teams.  In summary, the Trust managed this activity well, though attendance and admissions could sometimes become overwhelming.

 

Reference was made to a recent presentation by the North East Ambulance Service NHS Foundation Trust (NEAS) to the Tees Valley Joint Health Scrutiny Committee which showed NTHFT in a positive light compared to nearby Trusts in relation to ambulance waits.  Officers stated that ambulance data can be validated differently by other Trusts, and that it was NTHFTs aspiration to have zero 60-minute+ waits, something which was aided by the different entry-points to the University Hospital of North Tees (not just A&E) which other hospitals do not have.

 

A by-product of being a strong performer in terms of lower ambulance waits was that the Trust were sent patients from other hospitals where waits were generally higher – indeed, NTHFT received 144 diverts / deflections in December 2022 alone.  Once within a NTHFT site, the treatment of a patient depended on their presentation, and an individual could be transferred to another hospital (e.g. James Cook University Hospital, Middlesbrough) if a particular procedure was required.  The Trust works with STHFT regarding the transfer of patients but acknowledged there can be delays in some cases.

 

•         Accessibility: Several developments and improvements during 2022-2023 were outlined, including best practice training for when staff work with an interpreter, the introduction of Accessibility Champions, a refresh of the Terms of Reference for the Accessibility Meeting, the completion of a Disability Discrimination Act (DDA) access audit on the Trust’s hospital sites, and the initiation of a Patient, Public and People with Lived Experience (PPPLE) Steering Group to refresh the Trust’s approach to engagement.  NTHFT was also reviewing its complaint process to ensure equal access when raising a concern, complaint or providing feedback – this would provide greater assurance to patients, their families / carers, and Elected Members.

 

In addition to the elements listed, the Committee heard of improvements to the access points for the lung-health service.  Whilst this was welcomed, Members drew attention to reported issues regarding disabled parking bays and signage for those arriving to use this department (though it was noted that dedicated parking spaces for the service were already provided).

 

•         Violent Incidents: Aside from significant dips in July 2022 and August 2022, recorded monthly violent incidents during 2022-2023 were broadly similar to the same period (April to January) for 2021-2022.  Abuse of staff by patients continued to account for the large majority of incidents (88%).

 

Drilling-down into specific types of violent incident, most categories had seen a decline in 2022-2023 compared to the previous financial year, some significantly (i.e. concerns to do with personal safety; disruptive / aggressive behaviour – other; need for use of control and restraint with patient).  Less welcome was the nearly 20% rise in verbal abuse or disruption incidents.  Whilst it was encouraging to see an overall decrease in recorded cases, figures were still higher than desired, with many incidents not reported due to the Trust managing often challenging situations to the extent that it is no longer considered appropriate to record them.  Assurance was given that staff were supported in relation to dealing with such conduct from patients and visitors, and the police were called to assist where required.

 

Members repeated past frustrations that too many people still think it appropriate to direct aggression towards hospital staff, and queried if most of these incidents occurred in A&E.  NTHFT noted that A&E does have to deal with individuals who have been / are under the influence of alcohol and / or drugs, and that this can inevitably contribute to a person acting in a particular manner, though some patients will be challenging due to their underlying condition (e.g. dementia).  Again, the Trust was grateful for the support of TEWV colleagues for their role in supporting staff who face such behaviour.

 

Patient Experience

 

•         Friends and Family Test (FFT): NTHFT continues to see a high proportion of positive FFT feedback (via both text and paper-based routes), with again over 90% of the 16,504 responses during the April 2022 to January 2023 period rating it either ‘very good’ or ‘good’.  Those completing the FFT are but a fraction of the total number of contacts experienced by the Trust, but the introduction of a text-based option had improved response rates (particularly for emergency care and outpatients).  FFT data is processed weekly to allow for the prompt identification of issues, and any actionable comments are relayed to the relevant service for follow-up (including positive feedback which is, importantly, shared with staff).

 

•         Complaints: The recent trend for an increasing number of ‘Stage 1 – Informal’ complaints continued in 2022-2023 (April to January), though, as reported during last year’s Quality Account presentation, this was not necessarily a worrying sign as resolving issues quickly and avoiding the need for them to be escalated was seen as a positive.  This was further reflected in the number of complaints requiring a ‘Stage 3 – Formal Response Letter’ (82) which had again declined when compared to both 2021-2022 (85) and, more significantly, to 2020-2021 (111).  The overall increase in the number of complaints received by NTHFT (1,311) in 2022-2023 compared to the same period (April to January) in 2021-2022 (1,158) and 2020-2021 (951) could possibly be attributed to the restrictions on visiting caused by the COVID-19 pandemic and, more recently, industrial action which led to the cancellation of treatment (though it was noted that the Trust was progressing well on elective procedures).  Managing public expectations in light of these developments had been challenging.

 

In terms of complaint type, for the second year running, ‘attitude of staff’ (122) topped the list for 2022-2023 (April to January), ahead of ‘length of time to be given appointment’ (108), and ‘treatment and procedure delays’ (103).  It was felt that the perception of staff attitudes could be quite subjective depending on the circumstance in question, and the Trust managed cases by ensuring it liaised fully with services and their staff.

 

With reference to the recent strikes by NHS employees, and widely reported challenges around recruitment and retention, the Committee asked how NTHFT was ensuring it had, and maintained, a robust workforce.  Trust representatives spoke of several strands of staff recruitment and development, including nursing personnel (student training, growing their own, international recruitment) and providing opportunities for staff to progress, though questions around junior doctor numbers would be better directed at the NTHFT Medical Director.  Members added that education and training were clearly key.

 

•         Compliments: NTHFT was pleased to report that the number of compliments it received had increased in 2022-2023 (3,766) compared to the same period (April to January) in 2021-2022 (3,503).  When balanced against the number of complaints received, this gave an encouraging picture of the general level of satisfaction of the Trust’s service provision.

 

The presentation concluded with details of the Quality Account timeline for 2022-2023, and Members were informed that the Trust’s draft document would be circulated in late-April 2023.  Given that the existing Committee membership would change as a result of the forthcoming local elections, it was agreed that the Committee’s third-party statement for inclusion in the final NTHFT Quality Account document would therefore need to be prepared and agreed prior to the draft version being received.

 

The Committee thanked the NTHFT representatives in attendance for another comprehensive presentation which touched on numerous aspects of the Trust’s overarching offer, much of which was positive despite the ongoing challenges faced by NHS providers.  That said, Members expressed concern over the reported increases in collaborative working with STHFT and the fear that this was a potential move to the loss of local services which could be transferred to the James Cook University Hospital, Middlesbrough.  The Committee was advised that getting the right care in the right place was the key driver behind joint-working with STHFT.

 

Probing the current state of cancer care, the Committee heard that cancer pathways, along with emergency surgery, had been the priority since the emergence of COVID-19, and that the ability to conduct purely elective procedures at the University Hospital of Hartlepool enabled space for these priorities to be addressed at other NTHFT sites.  In related matters, it was also confirmed that the Urgent Care Centres in both Stockton and Hartlepool continued to work well and provided huge benefits to the Trust and, crucially, the local population.

 

Finally, with reference to concerns raised by the Care Quality Commission (CQC) following an inspection in 2022, as well as recently reported issues to Members around post-natal home-visits, Members proposed that maternity services be added to the list of the Trust’s Quality Account priorities for 2023-2024.  In response, NTHFT officers welcomed any new ideas for areas of future focus, though would need to consider the specifics of what needed to be assessed within maternity care, how it should be measured, and how this complemented existing data collection.

 

AGREED that:

 

1)       The update on performance and development of the North Tees and Hartlepool NHS Foundation Trust Quality Account be noted, and the requests for further information be submitted by the Trust.

 

2)       A statement of assurance be prepared and submitted to the Trust, with final approval delegated to the Chair and Vice-Chair.