Agenda item

Representatives of NTHFT will be in attendance in order to outline performance against the Trust’s quality priorities for 2023-2024 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 organisation’s Quality Account, a document which NHS Trusts had a duty to produce each year.

Beginning with a reminder of NTHFTs four key principles (putting our population first, transforming our services, valuing people, and health and wellbeing), the NTHFT Associate Director of Nursing, Effectiveness and Clinical Standards, supported by the NTHFT Associate Director of Nursing, Clinical Safety and Deputy DIPC, outlined highlights and developments in relation to the Trust’s performance (aligned to some of its Quality Account priorities) over the course of 2023-2024 as follows:

Patient Safety

•         Mortality Indicators: As of 1 April 2023, NTHFT no longer reported on the measure for in-hospital mortalities (Hospital Standardised Mortality Ratio (HSMR)) – however, this was included for information, with an increase in the January 2022 to December 2022 ratio compared to the December 2020 to November 2021 ratio.  In-hospital deaths plus those up to 30 days post-acute Trust discharge (Summary level Hospital Mortality Indicator (SHMI)) had decreased in 2022-2023 compared to the same reporting period (September to August) in 2021-2022 – a positive development considering the established inequalities within the local population and the associated challenges these create.  As far as the SHMI measure was concerned, NTHFT continued to perform very well in comparison to other Trusts across the region and nationally.  Trust raw mortality (people dying in hospital) data remained reasonably consistent when compared to previous years.

•         Dementia: The number of patients admitted with a diagnosis of dementia / delirium was largely consistent between April 2023 and November 2023 (ranging between 301 and 334 per month), and broadly replicated monthly admissions for these conditions during the same reporting period for both 2021-2022 and 2022-2023.  However, there had been a large drop in December 2023 (174), something the Trust was in the process of investigating.

•         Infection Control: Within the context of a challenging national outlook around Clostridium difficile (C Difficile), both of the Trust’s measures for this infection type had increased in 2023-2024 compared to the same reporting period (April to December) in 2022-2023 – cases detected in the hospital two or more days after admission (Hospital onset healthcare associated (HOHA)) had gone up by 11; cases that occurred in the community, or within two days of admission, when the patient had been an inpatient in the Trust reporting the case in the previous four weeks (Community onset healthcare associated (COHA)) was up by 5.  Both measures were over the NTHFT threshold.

There was a mixed picture regarding cases of other healthcare-associated infections during 2023-2024 compared with the same reporting period (April to December) for 2022-2023.  Methicillin-Resistant Staphylococcus Aureus (MRSA) (up from 1 to 2), Methicillin-Sensitive Staphylococcus Aureus (MSSA) (up from 29 to 37) and Escherichia coli (E.coli) (up from 63 to 68) cases had all increased during 2023-2024.  However, cases of Klebsiella species (Kleb sp) bacteraemia (down from 20 to 18), Pseudomonas aeruginosa (Ps a) bacteraemia (down from 12 to 8) and catheter-associated urinary tract infections (CAUTI) (down from 165 to 139) had reduced.

Working against the backdrop of a general rise in the prevalence of infections within hospitals across the North East and North Cumbria Integrated Care Board (NENC ICB) footprint, assurance was given that NTHFT colleagues were attempting to reduce these incidents (e.g. skin cleansing to prevent MSSA), with work being undertaken on a regional basis to better understand potential links between infections and deprivation (e.g. underlying health issues, poor general health / hygiene).  The decrease in CAUTI cases was encouraging given the similar level of catheters being used – that said, the Trust was trying to avoid the use of catheters in the first place where possible.

Given the increase in C Difficile cases, the Committee asked if the Trust had undertaken a deep cleanse of wards at any point.  NTHFT officers stated that, despite space being at a premium, the difficulties in decanting patients and equipment to other parts of a hospital, and the priority given to clinical need / demand, deep cleans had been completed and there were plans in place for those areas yet to be attended to.

•         2023-2024 Flu Cases: Incidences of flu within the Trust had seen a marked decrease during 2023-2024 compared to 2022-2023.  There had been two recent outbreaks which the Trust had managed to contain – as such, only small numbers of individuals were affected.  Staff flu vaccine uptake was around 50% – given the events of the last few years, a possible sense of vaccine fatigue may explain this low rate.

Referencing the staff vaccination rate, Members felt that many people would have lost faith in directions / guidance from official authorities following high-profile stories in the national media.  It was also noted that the SBC Executive Scrutiny Committee had enquired about the level of Council staff vaccine rates (numbers as well as percentages) at a recent meeting.

Effectiveness of Care

•         Accessibility: A number of developments and improvements had been made as part of NTHFTs commitment to ensuring the accessible information standard was met, headlined by the launch of the Trust’s updated website during 2023 which allowed users to make webpages more accessible.  Other elements included the continuation of best practice training for when staff work with an interpreter, regular meetings of Accessibility Champions to receive training to support patients (volunteer services were crucial here), Patient and Carer Experience Council (PCEC) meetings dedicating time to the sharing of good practice / examples of reasonable adjustments in order to meet the accessibility needs of patients, and the identification of priority remedial work from the previously completed Disability Discrimination Act (DDA) access audit on the Trust’s hospital sites.

Reference was also made to PLACE (patient-led assessment of the care environment) audits, the completion of the complaint process review to ensure equal access when raising a concern, complaint or providing feedback, and the appointment of a Co-Production and Lived Experience Lead whose remit was to increase shared decision-making, equality, diversity, reciprocity, patient and carer involvement, and accessibility.

Members commended the new website though drew attention to several out-of-date policies which were still showing.  NTHFT officers stated that the Trust had a Quality Assurance Council which reviewed published policies – this observation would be raised with the group following the meeting.

•         Violent Incidents: The total number of recorded violent incidents at NTHFT during 2023-2024 (401) had decreased when compared to the same reporting period (April to December) in 2022-2023 (460).  However, whilst there had been a reduction in cases of abuse of staff by patients (down from 405 to 323), the number of incidents involving abuse of staff by another person increased (up from 55 to 78).

Categorisation of each violent incident showed significant increases (possibly as a result of better reporting mechanisms) in the ‘need for use of control and restraint with patient’ (up from 21 to 78), ‘disruptive, aggressive behaviour – other’ (up from 42 to 71), ‘inappropriate behaviour and / or personal comments’ (up from 18 to 28), and ‘physical abuse, assault of violence – malicious’ (up from 7 to 25).  The number of incidents labelled ‘sexual’ had also gone up from 0 to 5.  On a more positive note, there had been significant decreases in cases of ‘verbal abuse or disruption’ (down from 219 to 114), ‘physical abuse, assault or violence – unintentional’ (down from 105 to 58), and ‘concerns to do with personal safety’ (down from 40 to 12).

Members once again expressed alarm at the number of violent incidents towards staff, something which may, in part, explain the increased need for the use of control and restraint with a patient.  NTHFT officers highlighted the work with Tees, Esk and Wear Valleys NHS Foundation Trust (TEWV) around a softer-touch approach with regards restraint, and also noted security presence in the Accident and Emergency (A&E) department to support staff, particularly during evenings.

Patient Experience

•         Friends and Family Test (FFT): April 2023 to December 2023 data from the FFT (received via both text and paper-based routes) continued to show a high level of satisfaction with NTHFT provision, with over 92% of respondents rating it either ‘very good’ or ‘good’.

Conscious of the Trust’s last published CQC report which focused on children / young people and maternity services, the Committee requested that the FFT results be broken down per NTHFT department and circulated.  Members also asked about the latest results from the NTHFT staff survey as they were the backbone of the organisation and, alongside patients, shaped the delivery of services.  Officers confirmed that the Trust was in the process of collecting feedback from the latest survey and could make this available if required.

•         Complaints: The number of complaints received and dealt with at ‘Stage 1 – Informal’ had decreased in 2023-2024 compared to the same reporting period (April to December) in 2022-2023 (down 122: from 1,161 to 1,039), as did those which escalated to ‘Stage 3 – Formal Response Letter’ (down 21: from 82 to 61).  However, the number of complaints reaching ‘Stage 2 – Formal (meeting)’ increased (up 18: from 68 to 86).  The total number of complaints received in 2023-2024 (1,186) for this reporting period had gone down compared to 2022-2023 (1,311) and had returned to a level seen in 2021-2022 when 1,158 were received.  NTHFT continued to work hard to reduce the requirement for formal response letters (Stage 3) and had found that outcomes tended to be better when informal face-to-face meetings were offered (where appropriate).

Analysis of the categorised complaint types showed a fall in the number of recorded cases of ‘attitude of staff’, though this remained the highest subject of complaints.  ‘Delays to diagnosis’ complaints had risen in the first three-quarters of 2023-2024 and were now the second highest complaint type, with ‘communication – verbal’ rising to third.  It was felt that these results may reflect the ongoing impact of COVID-related backlogs as well as staff strikes.

Responding to Member concerns about potential staff perceptions of being overworked / underpaid, NTHFT officers acknowledged the stresses involved in providing good quality care within the context of high demand.  The Trust tried to support staff in carrying out their duties and also set expectations around conduct – however, in some cases, complaints about staff attitude could merely involve a difference of opinion between professional and patient.

In answer to a query on the number of complaints (53) about discharge arrangements, the Committee heard that NTHFT was nationally recognised for its strong performance around discharge and its low level of handover delays – this did mean that NTHFT picked up cases from neighbouring Trusts who were experiencing challenges in these areas (further information could be provided around this if required).  The ongoing Urgent Care tender was also noted, with efforts being made to ensure similar arrangements were in place across the Tees Valley which would ultimately benefit all areas.

•         Compliments: There had been a significant rise in the number of compliments received by the Trust – 4,514 in 2023-2024 compared to 3,411 in 2022-2023 (April to December).  NTHFT Team Support Workers (TSWs) were being used to ensure these were collected and relayed to individual services for recognition, with staff-to-staff compliments now also collected to further aid the wellbeing and morale of the workforce.

This year’s presentation included a specific section on maternity which highlighted national safer care recommendations, the maternity and neonatal three-year delivery plan, and NTHFT developments involving community midwifery services, the Trust’s Maternity and Neonatal Voice Partnership, and specific areas of good practice (one of which (QI and research) the maternity service was a high implementer of, with a Trust Nurse recognised nationally for their work in this field).  The new NTHFT Associate Director of Midwifery post had made a significant impact on the planning and delivery of services, and whilst there were currently some vacancies within the Trust’s maternity structure, it was expected that workforce capacity would be in a stronger position come April 2024.

Set within the context of the Trust’s approach to quality and its existing strategic plan (Improving Together: Patient Quality Strategy 2023-2026), the NTHFT Quality Improvement Priorities 2024-2025 were outlined.  Areas highlighted included the Trust’s intention to publish and implement its Patient Safety Event Response Plan (PSERP) which incorporates four key priorities aligned to safety and culture learning, and ongoing dialogue with the NENC ICB regarding future arrangements involving the Commissioning for Quality and Innovation (CQUIN) framework.  Members commented on the apparent absence of a priority around the retention of staff (a well-documented issue which impacted on the provision of quality care), as well as previous criticism that the Trust had too many plans.  Regarding this latter point, the Committee heard that a lot of work had gone into reviewing NTHFT governance structures (strengthening the ‘ward to Board’ ethos), with an assurance framework which linked risks to strategic objectives.

The presentation concluded with the Quality Account timeline for 2023-2024, and Members were informed that the Trust’s draft document would be circulated in May 2024.  The Committee’s third-party statement would need to be submitted by the end of May 2024 for inclusion in the final NTHFT Quality Account document (which had to be published by 30 June 2024).

In other matters, the Committee highlighted the location of the Trust’s respiratory / lung health unit (being a significant distance away from the main reception area) and the poor state of the toilet / handbasin area.  NTHFT officers agreed to check the current situation regarding the latter, though gave assurance that the former was being addressed as part of discussions on potential alternative entry points.  Improvements had been made to communications for these patients in terms of clarity around access / support, though.

Finally, with regards the ‘Patient Quality’ dashboard example provided within the ‘Strategic Plan’ section, it was queried if NTHFT recorded whether a patient had a particular condition (e.g. autism) and then measured outcomes against the care provided.  Officers present stated that the Trust’s Vulnerability Team may be better placed to respond to this.

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.