Shared Interest Forum created

My fellow Governors have agreed to my suggestion that there should be a Shared Interest Forum for understanding the clinical performance of the Trust. I will be the facilitator and I and eleven other governors will comprise the group. Governors tend to concentrate on patient experience which of course is very important. However to my mind the critical issue for patients is how good the clinical care is e.g. clinical outcomes,. The latter is not so clear to patients or the public and when I put myself forward for election that is what I promised to concentrate on.

The Forum will be seeking to understand clinical performance by looking to see what clinical standards the Trust sets for itself, from where those atandards derive and what they mean in terms of ambition. We will work to understand to what extent the Trust meets its own standards and how the Trust compares will others in the locality and more widely e.g. nationally. We have decided to start with clinical performance in avoiding venous throboembolism and pressure damage/pressure sores. I will report from time to time on the results.

Eye Clinic Update

I was recently briefed by the Ophthalmology team on progress with the Eye Clinic improvements. The Clinic Manager computer system is in place but it was agree that the screens could be better placed and another would be warranted. Also what is displayed is not very clear to patients. They will address both these issues.

New staff have now been recruited and the new rooms are in operation. Some extra waiting space has been created. A drinks machine is being installed.

A new system for getting and tracking notes has been implemented with significant improvements albeit I have heard from one patient that it is not perfect.

A 'time and motion' study is underway to identify bottlenecks in patient flow. This will be used to see how to improve the worst aspects of the clinic – extremely variable waiting experience.

By July all improvements which are deemed possible with the current restrictions on space and equipment will have been implemented. A longer term business plan for extensive changes will then be presented to the hospital Board. I have been briefed on its essence and it will, if it comes about, be great for patients.

Finally a weekly one page summary of progress is now being produced and will be handed out to Eye Clinic patients.

I am pleased to say that the team has agreed to include in their deliberations an Eye Clinic patient who I nominated.

So far so good but some way to go which the Board and the Chief Executive both acknowledge.

Maternity Services

20% of all litigation claims in England involve maternity care and these represent 61% by value. Thus the RSCH belongs to the CNST (Clinical Negligence Scheme for Trusts). This scheme routinely assesses maternity units to ensure they comply with best practice thereby ensuring patients are safe and the likelihood of claims is low.  There are 4 levels of achievement: zero, 1, 2 and 3. Levels 2 and 3 are the highest and involve a gruelling assessment every 3 years. RSCH's maternity unit has just been assessed and has achieved the highest Level 3. This is not only excellent for mothers and babies but also means that the hospital receives the maximum insurance premium discount.

Part of the assessment checks that the midwife to mother/birth ratio is appropriate.

The Royal College of Midwives  and the Royal College of Obstetrics and Gynaecology both recommend a ratio 1:28. However they also recommend that hospitals should determine the ratio appropriate for them by using the Birthrate Plus toolkit into which data about type and volume of work and case mix etc. are fed with the output being the recommended ratio for safe and effective care.

The CNST assessment expects the ratio to be as determined by Birthrate Plus. If it is not then there has to be a plan in place to achieve it otherwise Level 3 would not be awarded.

I have made Freedom of Information requests to the major hospitals in Surrey to ascertain what there midwife to mother/births ratios are/have been over the last 12 months and their plans in the context of the RCM and RCOG recommended 1:28 or Birthrate Plus appropriate levels.

RSCH has been between 1:34 and 1:41 during 2012 against a Birthrate Plus appropriate level of 1:30. The Trust recognises that this is not satisfactory. A Business case for improvement has been accepted and the appropriate ratio of 1:30 will be achieved by 2014 – recruitment is underway.

For Frimley Park the Birthrate Plus appropriate level is 1:31. Through 2012 the level has been in excess of this: the Chief Executive has decided on a level of 1:33. There is a plan to work to 1:31 by 2015.

At Ashford and St Peters the ratio as of March13 was 1:31. They seek to reduce this to "national requirements" over the next 3 years.

St Heliers state that over the last 12 months they have always complied with the RCM's recommended ratio of 1:28.

Car Parking

Very regretfully the RSCH will increase car park charges from 1 April and payment will now be by the hour instead of in 2 hour slots. The hospital claims that charges are in line with other major hospitals. On the brighter side the cost for parking for 6 to 24 hours has been reduced and there are no changes in the cost of weekly tickets or for the Oncology patients' car park. Blue badge holders will continue to have free parking in designated disabled bays. Why blue badge holders cannot have free parking in any bay is a mystery to me.

If there is an upside it is that the increased revenue will assist the hospital to move to a better parking system and get rid of the present hated way of paying up front and topping up. It is hoped in due course to return to pay on exit e.g. by automatic number plate recognition, as well as providing the opportunity for card payments. Strategically a multi-story car park is recognised as the answer.

Finally there will be more public parking spaces. 32 staff parking spaces are being converted to public spaces – good for the public, bad for staff!!

Dementia

I reported in an earlier blog that RSCH was becoming very active in providing care specific to patients woith dementia. That work is continuing well. I have now joined the Trust's Dementia Steering Group and have attended my first meeting. The Group is impressive and includeds representatives of the University which is active in research in this area, the County Council and the Alzheimers Society.

The hospital has just been subject to a National Dementia Audit  which includes an organisational checklist and an audit of the case notes of 40 patients. Overall performance was good. Of the 47 questions which relate to the most serious matters, the hospital needed to improve on 4. Of the 94 questions  on standards which RSCH should be expected to meet in normal practice, 12 needed improvement and of the 11 questions which RSCH should meet to achieve excellent practice there was just one where improvement was required. Action is in place to achieve improvement wherever that was deemed necessary.

Proposed staff reductions

I have been asked a variety of questions following reports in the media of proposed staff reductions in the Royal Surrey so this is what I know. As in all Trusts financial pressures are great putting pressure on the hospital to make savings. The following is what is proposed and is now subject to consultation with unions.

Ø All vacancies are being reviewed and cannot be filled without permission of senior management

Ø Strenuous efforts are to be made to reduce the use of agency nurses

Ø Loss of one specialist palliative nurse

Ø Loss of one specialist gynaecological nurse

Ø Loss of one care assistant on each ward

Ø Some sharing of medical secretaries

Ø Some loss of non-frontline staff

There will be no loss of consultants or other medical staff.

Governors have been assured that all this has been formally risk assessed to ensure that there is no danger to patients.

Naturally I and other governors do not welcome loss of staff particularly frontline staff such as nurses. Of course we will watch out for any significant deterioration of quality of care and should we have concerns will make our views clear. However it has to be recognised that is exceedingly difficult to associate any deficiency to a staff reduction with any degree of certainty not least because we all know that care staff will as always up their effort to ensure patients continue to be well cared for. I am particularly sad to see the loss of a specialist palliative nurse and the impact it will inevitably have on those who are experiencing the ultimate in suffering.

Mortality statistics

When I sought election I said I would concentrate on looking at information about clinical outcomes in areas which are life threatening or life changing. One of those areas is mortality statistics. I have spent the last 5 months collecting data on hospitals in the S.E. and getting to grips with the intricacies of the various mortality indices which hospitals use. There are five: one national from the NHS Information Centre (NHSIC) which everybody uses, two from the company Dr Foster  and two from the company CHKS. RSCH uses the CHKS's.

The first thing to say is that having five different indices is a mess. One of the indices from CHKS is terrible (NHSIC agrees) and its meaning is widely misunderstood including within RSCH. I am pleased that RSCH has agreed not to rely solely on this indicator. One of the recommendation from the recent Francis Report on Staffordshire Hospital recognises that it's all a mess and calls for an in-depth review. I intend to do what I can to encourage that review (I will report on that another time).

Pleasingly RSCH is in the top 15% judged by the national NHSIC index (an excellent indicator). Its value indicates that for RSCH deaths are about 10% lower than would be expected. However this index looks at deaths in hospital plus deaths outside within 30 days of discharge. It needs therefore to be used in conjunction with an index or indices which deal solely with deaths occurring within the hospital. For that purpose RSCH uses the two indices from CHKS.

I have examined RSCH's monthly Performance Reports for 2012 to see how it reports on mortality and have looked also at Dr Fosters indices for RSCH and various national data. Just before I was due to discuss what I found with hospital staff:

Ø Dr Foster published its 2012 statistics on mortality;

Ø The Francis Report was published throwing a spotlight on how hospitals handled their mortality statistics (it was Dr Foster's statistics which threw Staffordshire Hospital in to the limelight).

These events have caused a flurry of media interest with the Department of Health announcing an investigation of mortality in a number of hospitals where Dr Foster and NHSIC indices look particularly bad. RSCH is not one of them but, like all hospitals, it has been stimulated to look closely at its figures.

Even though its performance judged by the NHSIC index is very good, its performance judged by the recent Dr Foster publication is not. The hospital is determined to discover why. One of the likely reasons is technical in that, where a patient is receiving palliative

care and thus likely to die, the hospital is failing to capture that fact in its coding of the patient's care episode. Indeed in national statistics RSCH appears to have far fewer deaths coded palliative than the great majority of other hospitals. The affect of this deficiency in coding is to make the mortality index worse than it would be if coding was better.

I have met with the Medical Director and the Chairman of the Board and discussed the reporting on mortality in Performance Reports, NHSIC and Dr Foster's figures and the matter of coding of palliative cases. The meetings have been extremely constructive and results will be fed in to the major review of coding and mortality which the hospital is undertaking in the light of the Dr Foster data and backlash of the Francis Report. Nothing to date leads me to believe that quality of care is poor.  I am being kept in the loop. RSCH will not be the only hospital taking a good look at how it deals with its mortality statistics and that can only be good for patients.

I have also been looking at cancer survival rates – more later.