As you know, the Sir Robert Francis report, commissioned to look at how the provision of care for patients looked after at Mid Staffs failed so dramatically, was published last week.
The report will prompt questions from family and friends about how it could happen in a UK hospital, and does it happen where we work. In this context I thought it might be helpful to share some of the feedback and some of the information I am aware of about the services we provide through SASH.
Over the last two years the trust has moved from delivering very few of the national quality and safety standards, to delivering them all. We have done well on reducing the number of patients who have long delays in being treated in the Emergency Department and are performing well on the 18 week referral to treatment pathway. In addition to this we are keeping more people out of hospital for their care by developing ambulatory pathways in partnership with GPs.
Working with GPs in both Surrey and Sussex the trust is developing new ways of supporting the elderly who are looked after in nursing and care homes and supporting their out of hospital care for often very complex and challenging health needs. These are areas where the new way of working with our clinical commissioners will work to patient benefit across both counties.
Ward hygiene and cleaning scores, IV line and urinary catheter care and antibiotic prescribing audits have all improved to high levels of quality and safety. Against this background the trust has performed very well this year for CDiff infections and although it has experienced two norovirus outbreaks it has contained these more quickly than previously, with fewer patients either contracting noro, or affected by ward closures.
The number of complaints the trust receives has fallen dramatically and there has been a coincident increase in concerns expressed and managed by the PALS service. That such problems can be raised and addressed in real time, face to face, is much more satisfying for patients and for the staff involved and offers the opportunity for us to put right what has gone wrong faster and put less patients at risk. Patient feedback system, Patient Opinion recently singled us out as one of their most improved trusts for patient experience.
At SASH, money has been spent in increasing in doctors and nurses, and midwives. We have doubled the number of consultants in the Emergency Department, and increased consultants in many other services across the trust. This, with changes in the way in which doctors are working has enabled more cover to be provided at times of peak demand, and has raised the seniority of opinion easily available in the evenings and at weekends. The trust has increased the number of obstetricians and midwives allowing 98h per week of consultant presence on the labour ward, and reducing the ratio of women to midwives significantly.
Our commissioners have consistently told me over recent months that they have noticed that SASH is different than it used to be. It is right that we continually question how we make decisions that impact on patient care, how we spend tax payers’ money and how we ensure quality and patient experience are at the heart of all we do.
Des Holden, Medical Director
Performance
The latest monthly results are for December 2012 and the Trust is rated as “Performing” for the Quality of Services.
Significant points of note regarding performance include:
• Winter pressures adversely effected emergency department performance
• There were no incidence of MRSA and one incidences of C-Diff during December resulting in C-Diff being 14.25 cases below the straight line YTD trajectory and MRSA 0.25 below the YTD trajectory.
• RTT performance continued as expected with the 90% Admitted, 95% non-admitted and 92% incompletes measures all being achieved in aggregate.
• Delayed Transfers of Care continued to be below the 3.5% standard.
• Following achievement of no mixed sex breaches for the first time in July, this performance was sustained into December.
Infection Control
Both MRSA and C-diff have seen significant improvements. The number of MRSA cases has reduced by over half as compared with the same period year-to-date last year and there have been 18 cases of C-diff year-to-date compared to 39 cases in the same period last year.
The infection control task force continue their increased focus on good antimicrobial stewardship, driven primarily by the hospital’s medical staff and pharmacists which is reflected by significant improvements over recent months in compliance with the monthly Good Antimicrobial Prescribing (GAP) audits.
Norovirus continues to be present in the community. In order to reduce the risk of introducing new cases into the acute hospital setting where risk of cross transmission to vulnerable patients and staff is high, suspected cases should be managed in the community where possible and practical.
Please consider the following when assessing patients:
• Has your patient had diarrhoea and/or vomiting within the last 48h? If so is an infectious cause likely?
• Can your patient be safely managed with supportive/symptomatic care in the community: oral rehydration (or IV/subcutaneous if appropriate) and anti-emetics?
• Has your patient been in contact with a suspected or confirmed case of viral gastroenteritis within the last 48h?
If hospital admission for suspected cases or contacts is unavoidable then please ensure that symptom and exposure history is clearly communicated to the triage/admitting team.
Detailed information on Norovirus symptoms and management plus useful information for patients can be found on our website:
Improving Discharge Times
Pharmacy is often held out as a delaying factor for discharge but a new report shows for January 83 per cent of TTOs were completed within one hour and the average time to completion was 39 minutes. This is even better than the average time for December, which was 46 minutes with 96 per cent completed within two hours. One of the delaying factors is the time taken to deliver TTOs back from the pharmacy. To help solve this problem, we are recruiting a pharmacy assistant to help deliver TTOs back to the wards in the mornings, and deliver medicines to the wards in the afternoons, and if a patient has moved to another ward they will take the medicines to that ward to prevent medicines having to be re-dispensed. A simple solution, but one that will save a lot of time and help get patients who are ready to go home, discharged faster.
The Busiest Blue Light Emergency Department in the South
NHS Information Centre has published its latest figures on the use of emergency departments around the country last year. Of the total 73,000 attendees at East Surrey Hospital’s Emergency Department from April 2011 to March 2012, 36 per cent of people (26,200) were discharged without any follow-up; 22,000 patients were discharged with a referral or a follow-up with their GP; and 20,100 patients were admitted. Almost 40 per cent of patients arrived by ambulance, and 20 per cent of these cases are aged between 80 and 89 years.
These figures back-up what we know already: We are a very busy hospital with an elderly population, and we are the busiest blue light hospital in the South. We have on average 95 ambulances per day – that’s 33,000 per year.
A seven consultant rota is now in operation, increasing senior cover in the department during the evenings and at weekends. The re-attendance within seven days target of below five per cent has now been achieved and there is on-going work to reduce this further.
Ambulance handover times and the embedding of a ‘see and treat’ model remain key areas of focus, there has been improvements made and we are working with external partners on resolving further issues. It should be noted that data quality / system issues are being managed with SECAmb, the owners of the system. Performance remains static and we have introduced an on-site practitioner from SECAmb to support the handover process, this is being well received by all.
Maternity Unit win the Pools!
The busy maternity unit has won a £400,000 cash injection from the Government’s Maternity Grant.
It’s great news for expectant mums as the money will be spent increasing the numbers of birthing pools at East Surrey Hospital from one to four. A big thank you goes out to all the new parents who helped us win the grant – in just a few days 430 people filled out surveys supporting the unit. Mums and dads told us they wanted a more homely environment and more birthing pools and this is what we based our bid on. This money allows us to give women a choice in how and where they give birth.
The staff at the hospital deliver more than 4,500 babies a year, making it one of the busiest maternity units in the area. Birthing pools are chosen by many women as a way of helping to manage pain during labour. One of the new pools will go into the high risk area so women who have complications during labour will also have the chance to use a pool. Work in the department has already started and should be finished by the end of March.
The award is part of a £25 million investment programme by the NHS in maternity facilities and was the largest amount given to a hospital in this area.
Also last month maternity scored full marks for safety in the Clinical Negligence Scheme for Trusts. The assessment process focused on how the hospital manages the safety of women and their babies. Achieving 50 out of 50 in the CNST (clinical negligence scheme for trusts) level 1, means that maternity services can now fast-track to level 2 later this year.
SASH Mortality Lower than Expected Rate
The Department of Health produced its latest data on the Summary Hospital-level Indicator (SHMI) which reports mortality at trust level across the NHS in England. The SHMI is a ratio of the observed number of deaths to the expected number of deaths either in-hospital or within 30 days post discharge from the hospital. Our Trust has continued to demonstrate a lower than expected rate for the period July 2011 to June 2012 and this is a further improvement on our position in the last quarter. This is an excellent achievement for the Trust, and puts us 31st nationally from the 142 Trusts who have been assessed and third in the South-East Coast region.
Top Marks for Blood Service
Did you know that we issue approximately 15,000 blood products each year? And what’s more, for the past three years we have achieved 100 per cent traceability for every single one of those blood products (Jan 2010 to Dec 2012). Under the Blood Safety & Quality Regulations it is a requirement to know the unambiguous fate of all blood components and keep accurate computer records for at least 30 years. On average the majority of other laboratories in the UK are only achieving between 85-98 per cent traceability, so this is a superb achievement and thanks goes to all the nurses, health care assistants, porters and the transfusion team who have all played their part in ensuring the highest possible level of quality and safety for patients.
Welcome Susan Aitkenhead – Chief Nurse:
Susan is a registered nurse with clinical, policy and operational experience in the NHS, central government, regulatory, commercial and higher education sectors.
Working as a professional adviser at the UK nursing and midwifery regulatory body; she was then seconded to the Department of Health to provide advice and support to ministers and policy officials across central government departments, later returning to the NMC in a senior advisory policy and strategy role with a spell of Acting Director Standards and Registration.
She moved for a short period into a role as the Lead Nurse for an international health software company and gained some commercial sector experience in finance, customer care and marketing; returning to the NHS as Associate Director for Nursing at Imperial College Healthcare NHS Trust in London, where her portfolio also included pre and post registration education. She has recently enjoyed the opportunity of working as executive director of nursing and midwifery in Australia and experiencing the delivery of healthcare overseas.
Susan says: “One of the first things I am doing is to establish a SASH nursing and midwifery strategy to clearly demonstrate the positive difference we make to patient outcomes, experience and care. This will sit alongside our Trust aims and objectives and values, and also incorporates the recent principles set out in the national work on Compassion in Practice. I am running forums with the Trust’s nurses and midwives to get their ideas and proposals so everyone can be personally involved in shaping and owning important strategy.”
“We need to identify how we disseminate good practice and innovation across the Trust and ensure we work as one to drive out any inequities in care and experience across the Trust. Key to this is learning from each other and externally, and being transparent and honest, particularly when things don’t go as well as they should – and everyone being empowered no matter what their role, to have their voice heard and their suggestions put forward. There is a determination here within the executive team to empower clinical staff in decision making and transparency in all that we do, which made this role very attractive to me when I applied for it; and I continue to see this being driven forward on a daily basis.”
Health Tourism Fraud
The recent media coverage of “Health Tourism” is timely and welcome publicity on an important type of NHS fraud. “Health Tourism” covers a multitude of activities but the outcome they share in common is that people receive non-emergency hospital healthcare in the UK that they are not entitled to, unless they pay for it.
Panorama reported that some GP practice staff were taking payments to ensure registration applications are successful. Registration with a GP is perfectly legal for anybody visiting or temporarily staying in the UK. Anybody in the UK regardless of their immigration or residency status has the right to free primary and emergency healthcare services. A practice should process and decide upon such applications as with any others, by reference to their policy, and that process should absolutely not include payment or a “signing on” fee, to the GP, the practice or its staff. All such payments are illegal.
The registration with a GP is a key first step for a would-be fraudster, because a registered patient, regardless of their entitlement, might be referred by their GP to a secondary care provider (such as this Trust) for non-emergency elective care.
Under the Bribery Act it is now illegal not only to make / take such a payment (to ensure the registration application is successful) but the organisation suffering the loss may also be prosecuted for not having taken reasonable measures to prevent / detect such payments. It remains unclear as yet whether the “organisation” in such a case would be the PCT/CCG (whose commissioning funds had been defrauded) or the practice as the employer of the bribed employee.
If you have any concerns about fraud and/or bribery, please do not hesitate to contact the Trusts fraud expert on 01732 424147 or 07824307370, or by email at stuart.doyle@parkhill.org.uk or stuartdoyle@nhs.net