Hyper Acute Stroke Services (HASUs) to stop at Royal Surrey in January

I have mentioned in previous blogs that a review of stroke services by CCGs had proposed that there be only three HASUs in Surrey i.e. at Frimley Park, St Peters and  East Surrey. That would mean that the HASU at the Royal Surrey would close and anyone with a suspected stroke would be taken by ambulance to St Peters (those to the south of Guildford would go to Frimley Park).

There is to be a public consultation early next year but, as I have pointed out before, I believed that the consultation would be meaningless and now that is clear. The Royal Surrey has just announced that as from January it will cease to provide HASU services and so patients in Guildford with suspected stroke will go to St Peters. Although the decision might be right for quality of care for the people of Surrey as a whole, this is a serious change in services provided by the Royal Surrey and of great concern to the public it serves. Despite this there has been no meaningful engagement by the Royal Surrey with its public or with its Members or with its governors. I chair the Patient Experience Committee. At its last meeting just 5 weeks ago stroke services was on its agenda but no hint of this forthcoming decision was given.

The Royal Surrey is a membership body which governors represent and in this case it is the people of Guildford who will be most affected. Time from suspicion of stroke to treatment is critical and, for those in Guildford, travel times by ambulance will be longer. Although this is but one factor to consider it is an important one. As one of the elected governors for Guildford I have repeatedly raised the matter of the CCGs stroke review but with little meaningful response. In this instance Royal Surrey’s engagement with those it serves scores very poorly.

You know about HASUs so what about ASUs?

In previous blogs I have reported that that 3 Clinical Commissioning Groups have collectively decided that the number of Hyper Acute Stroke Units (HASUs) in Surrey should be reduced from 5 to 3 and be located in Frimley, St Peters and East Surrey hospitals. The Royal Surrey will lose its HASU and those who have stokes in Guildford will be taken to St Peters and those south of Guildford to Frimley. There will be consultation in Jan/Feb next year but I cannot see this decision being changed.

However the question arises as where patients will go when their spell in the HASU has ended. The argument may be that those from Guildford in St Peters HASU should transfer to an Acute Stroke Unit (ASU) in St Peters itself assuming acute care is still required. However many patients having completed a HASU spell, might wish to be transferred to the Royal Surrey for further acute care prior to going home or to a rehabilitation unit in a non-acute setting. This would allow patients to be close to family and friends during what is often a difficult time.

The downside would be moving away from the clinicians who have treated you at the most dangerous time. However that is soluble given some joint working between St Peters and the Royal Surrey. The same issues arise of course between Frimley and the Royal Surrey.

Here then is an area where consultation could actually be meaningful provided of course the authorities are prepared to listen !!

Another hospital rating system

We have become familiar with Care Quality Commissioner’s inspections and ratings. In the last round Royal Surrey was ‘Good’, Frimley ‘Excellent’ and St Peters ‘Requiring improvement’.

Now the NHSI (NHSImprovement) has introduced ‘The Single Oversight Framework’ designed to help NHS providers attain, and maintain, Care Quality Commission ratings of ‘Good’ or ‘Outstanding’.

The Framework aims to help NHSI identify NHS providers' potential support needs across five themes:

·         quality of care

·         finance and use of resources

·         operational performance

·         strategic change

·         leadership and improvement capability

The Royal Surrey has received a rating of ‘3’, Ashford and St Peters ‘2’ and Frimley ‘1’.

The meaning of the ratings are roughly:

1.    No potential support needs identified.

2.    Targeted support needed: there are concerns in one or more themes.

3.    Mandated support needed for significant concerns: there is actual or suspected breach of licence, and a Regional Support Group has agreed to seek formal undertakings from the provider or the Provider Regulation Committee has agreed to impose regulatory requirements.

4.    Providers in special measures.

Whilst not good, this is not surprising given the Royal Surrey’s very poor financial position and that it is seriously missing some key targets such as cancer waits. Whereas every effort is being focussed on improving it is going to take time to get back to past performance. At least the hospital has decided not to merge with Ashford and St Peters allowing senior staff to concentrate on getting the hospital back onto an even keel.

Stroke review.   As I noted in an earlier blog a formal consultation is promised on proposed alteration to stroke services in Surrey as a result of a review by Clinical Commissioning Groups. Despite promises of consultation, plans are being put in place for implementation. So I do not expect any consultation will make a difference. In essence there will be just three Hyper Acute Stroke Units in Surrey and they will be in Frimley Park, St Peters and East Surrey hospitals. The Royal Surrey will lose its stoke unit and patients with a stroke in the Guildford area will go to St Peters in Chertsey. Those having a stoke to the South of Guildford in the area bounded by Cranleigh, Haslemere and Elstead will go to Frimley Park. Already staff in the Royal Surrey are being spoken to re their future and St Peters is looking to off load some of its patients to the Royal Surrey to create bed space for more stroke patients.

Turning the Royal Surrey around.  The Royal Surrey continues to strive extremely hard to turn itself around financially. Many savings are being made with most coming from a reduction in staff numbers and in expenditure on Agency, Bank and Locum staff. Nevertheless the deficit at the end of the financial year is unlikely to be substantially different from last year save for the expectation of a substantial financial injection subject to conditions laid down by NHS Improvement which continues closely to monitor the hospital’s progress. Times are really tough and that goes for all hospitals.

On the non-financial side NHS Improvement expects improved performance on A&E waits and cancer waits. My main concerns have focussed on cancer waits particularly the 62 day wait target from GP referral to treatment. The hospital performs very poorly in the area of urology a fact which I point out at every opportunity to push for more determination and detailed plans to sort matters out. I hope this is coming about. Some patients referred from other hospitals arrive at the Royal Surrey after much of the 62 day wait has been expended and sometimes after 62 days have already elapsed. This is a disgrace and requires strong representation to these offending hospitals at a CEO to CEO and Chairman to Chairman level which I will monitor to see that it happens. The relevant Commissioning Groups have a responsibility here also

The Sustainability and Transformation Plan for Surrey Heartlands. Very hectic activity is underway to review all the acute and community health services and social services in Surrey Heartlands (an area bounded roughly by Woking and Ashford to the North, Haslemere to the South. Guildford to the West and Epsom to the East). Very substantial changes to services and health institutions in this area can be expected. A public engagement plan is being put in place for later this year/beginning of next. I am one of the governors on the ‘Stakeholder Engagement Group’ and will report from time to time. I am watching A&E services, maternity services and cancer services in particular to see how they might impact on the Royal Surrey. An earlier blog reports that the Royal Surrey is to lose its stroke services and I fear lest it also loses its A&E and Maternity services to become not a General Hospital as now but just a Cancer Centre. That is not a current proposal but I fear the direction of travel. More to come in due course.

The Royal Surrey to lose stroke services

For some time the Surrey Clinical Commissioning Groups (CCGs) have been reviewing the provision of stroke services and, for W Surrey, have concluded there should only be two 'Hyper Acute Stroke Units (HASUs). They propose they be at Frimley Park Hospital and at St Peters Hospital. The Royal Surrey in consort with St Peters has indicated its agreement. 

The purpose of limiting the number of HASUs is to make sure each has a sufficient number of patients to build experience and  expertise and to ensure they are big enough to justify top level equipment and supporting services. St Peters is expert in cardiology and vascular surgery which tips everything in its favour. It has been shown that patients have a much better chance of survival and of avoiding post -stroke complications in large and well equipped HASUs. The centralisation proposed is therefore aimed at better clinical outcomes.

On the other hand speed is of the essence in strokes. It is essential to get patients to a HASU as soon as possible and certainly within a clinically reasonable time. The CCGs has studied ambulance travel times from all the points in West Surrey and is claiming that clinically reasonable ambulance travel times can be achieved with HASUs in only Frimley Park and St Peters. Ambulances with stoke patients would no longer go to the Royal Surrey and it will lose its existing stroke facilities which have always been highly rated in external audits.

Clearly for residents of Guildford and environs (and other places) ambulance travel times will be very substantially increased and will be a  matter of obvious concern.

The CCGs have an obligation to consult the public and this it will do  from July to September. Nevertheless the chance of anyone changing their mind is, in my view, minuscule (an advert for a Clinical Director for St Peters is already underway).

New Chief Executive

The Royal Surrey County Hospital has appointment Paula Head as its new Chief Executive. She will start in the Autumn.

Paula has Board experience in both the acute trust and community setting. She trained as a pharmacist and rapidly progressed to management roles within this field. She then joined the NHS where she held a number of strategic and operational roles, including having responsibility for a number of the operational and clinical departments in an acute trust.

Currently she is Chief Executive at Sussex Community NHS Foundation Trust and has seen the Trust through its successful application to achieve Foundation Trust status. Prior to that she spent three years at Frimley Park Hospital as the Director of Transformation.

She faces an enormous challenge in tackling the hospital’s serious financial difficulties. One of her first tasks will be to appoint a new Finance Director.

Royal Surrey’s 2016/17 budget

The Royal Surrey has set its budget for this financial year (2016/17).

It ended last year with a disastrous deficit of over £11 million resulting in an investigation by NHS Improvement (previously Monitor). The latter will report soon and I expect it to be justly highly critical of budget control and governance. The main cause of the overspending was the recruitment of 200 extra staff for which, in essence, there was no money.

The budget deficit for this year has been set at a staggering £17 million – vastly worse than last year!!! I had hoped to hear that it had set a budget aimed at least at reducing the deficit. The only slight glimmer of hope is that the hospital has set a ‘stretch target’ of saving an extra £7 million over and above the massively challenging savings already listed in the budget. If those extra savings are delivered the outturn will at least be no worse than last year. This will be the challenge for the new turn-around Director who is impressive but not a magician! Governors have asked for monthly reports on progress so as not to be caught out again. One problem will be that although projects to create savings are being urgently formulated they take time to bite and 16% of the financial year has already passed by.

Monitor is to investigate the Royal Surrey

I have just heard that Monitor (he body responsible for overseeing all Foundation Trusts) will be formally investigating the Royal Surrey for two reasons

• its sudden runaway financial deficit which it failed to control through proper governance arrangements re top executives and the board
• and its deterioration in performance against key targets and standards particularly A&E waits, the 62 day cancer standard and cancer 2 week (breast) standard

Governors have, during last year, expressed concerns that  doubling up of responsibilities at senior level when the CEO Nick Moberly left was unwise and would overload senior staff when there was the  added risk of eyes being off the ball with concentration on the merger. This is reflected in Monitor's concerns. Also I have several times expressed worries about serious breaches of the 62day cancer standard. Under processes concerned with formal Trust Quality Accounts, Governors are empowered to choose a standard for external audit. We chose the 62 day cancer standard.

Thus I certainly welcome the Monitor investigation.

The Trust has appointed a 'turnaround' Director who is now in post.

(Monitor has changed its a name very recently to 'NHS Improvement' - what a waste of money)

Royal Surrey shortlisted for awards

The Trust has been shortlisted for both the Patient Safety and the Quality Improvement prizes at the annual CHKS Top Hospitals Awards.  CHKS is a large company which provides data and information processing throughout the country and internationally.

The Patient Safety accolade is a national award for outstanding performance in providing a safe hospital environment for patients and is judged against a range of indicators, including hospital-acquired infections and mortality. It has been shortlisted with 4 other hospitals

St Luke’s Radiotherapy Service’s was shortlisted for the Quality Improvement category, which recognises developments in patient care and experience, as well as staff welfare, safety and morale. Royal Surrey has been shortlisted for this award alongside Hospital Magalhaes Lemos in Portugal and The New Victoria Hospital in Kingston-Upon-Thames, Surrey.

 

The winners of both prizes will be announced during a special ceremony at London’s Guildhall on May 10.

Merger pauses

In my last posting I mentioned that The Royal Surrey's financial position was 'dire' and 'unsustainable'. I have now been informed that the position has become so bad that the hospital has to concentrate all its efforts on swift and painful corrective action. They have therefore decided to 'pause' the merger.

Immediately the Trust will advertise for a new and permanent Chief Executive, a new Finance Director (the existing one announced a month ago that he had a new job - nothing to do with he financial meltdown) and a 'turn around' Director. All vacancies are frozen.

The causes of such a rapid deterioration are many and complex bur  revolve around failures to control departmental budgets and staff costs including agency staff and  ballooning drug costs. Governors are determined to know more and what steps are to be taken to guarantee a quick return to stability.

As for the merger the position, it will be reviewed in about 6 months but I cannot see it happening within 18 months at best if it happens at all.

Royal Surrey financial position

At the Board meeting today the Board Chair  described the financial position of the Royal Surrey as 'dire' and 'unsustainable'. The Royal Surrey is not of course alone in experiencing financial deficits. Whereas the proposed merger with Ashford and St Peters will result in financial savings these will not be evident for at least 18 months or more. Difficult decisions are in the offing albeit the Executive and Board are determined that. whatever is done. it will not compromise patient safety.

Merger latest schedule

The latest schedule is

• Monitor (the body which oversees Foundation Trusts) issues risk rating end July. If all OK
• Boards of both Royal Surrey and Ashford and St Peters approve merger late August
• Both sets of Governors vote on merger early Sept. If both in favour
• Merger formally takes place 1 October.

Ads for the new Chief Executive, the Chair and the new Non-Executive Directors have been placed.

Merger update

 

For about 12 months the Boards of the Royal Surrey and Ashford and St Peters have been active in developing the Business Case for the proposed merger. The governors’ Merger Working Group which I chair has also been very active in challenging the case wherever concerns have arisen. Governors have not always been successful in realising the changes they would have liked but can claim some credit.

 

Last week the Boards approved the final case and it has now been submitted to Monitor (the body that oversees Foundation Trusts). Monitor will crawl over it and in a few months revel its conclusions in the form of its view of the level of risk which the merger presents. A ‘Red’ rating will doubtless stop things in their track and cause a considerable rethink. ‘Amber’ will result in a reassessment in the areas causing concern and ‘Green’ will of course lead the Boards to proceed rapidly towards formal merger.

 

If the rating is Green then in about May/June both Boards will meet to formally approve a merger and immediately after that each Council of Governors will be asked to approve. A majority of Governors on both Councils have to approve for the Merger to proceed.