Birmingham Children s Hospital NHS Foundation Trust. Progress against the recommendations of the Healthcare Commission s intervention report

Transcription

1 Birmingham Children s Hospital NHS Foundation Trust Progress against the recommendations of the Healthcare Commission s intervention report June 2010

2 About the Care Quality Commission The Care Quality Commission is the independent regulator of health care and adult social care services in England. We also protect the interests of people whose rights are restricted under the Mental Health Act. Whether services are provided by the NHS, local authorities or by private or voluntary organisations, we make sure that people get better care by: Driving improvement across health and adult social care. Putting people first and championing their rights. Acting swiftly to remedy bad practice. Gathering and using knowledge and expertise, and working with others.

3 Contents Introduction 3 Findings 4 Recommendation 1 4 Recommendation 2 5 Recommendation 3 8 Recommendation 4 9 Recommendation 5 11 Recommendation 6 12 Recommendation 7 13 Recommendation 8 14 Recommendation 9 15 Recommendation Recommendation Recommendation Conclusions 20 Birmingham Children s Hospital NHS Foundation Trust: Summary of progress with recommendations 2

4 Introduction The Healthcare Commission s intervention report, which was published in March 2009, looked at concerns related to the paediatric tertiary care (that is, specialist healthcare) services provided by Birmingham Children s Hospital NHS Foundation Trust (the trust) in the specialty areas of renal transplants, liver transplants, craniofacial surgery, neurosurgery and interventional radiology. The trust works with University Hospital Birmingham NHS Foundation Trust (UHB) to provide these services. At the time, the Healthcare Commission considered what concerns had been raised about the paediatric tertiary care services provided by the trust, the extent to which they impacted on the safety of the trust s services, and the way the trust and other stakeholders had responded to these concerns once they had been made aware of them. The Healthcare Commission concluded that a number of improvements were needed at the trust and made 12 recommendations. The Care Quality Commission (CQC) has taken over the work of the Healthcare Commission and we have completed an assessment of the trust s progress against the recommendations of the report as at November Methodology The follow-up of the intervention involved: A review of documentation. We asked the trust to provide a statement on how it had addressed the recommendations. The trust also provided a range of documents as evidence of the progress it had made. A follow-up visit to the trust and UHB by a CQC review team, which included two external clinical advisers, to interview members of staff. Asking Monitor, Heart of Birmingham Teaching PCT (the trust s main commissioning primary care trust), the National Commissioning Group and the Chair of the Task Force Group (responsible for monitoring the implementation of the trust s action plan) for their assessments of how the trust had addressed the recommendations from the report. Birmingham Children s Hospital NHS Foundation Trust: Summary of progress with recommendations 3

5 Findings Our findings are set out below and follow the order of the original recommendations made by the Healthcare Commission. The trust has made progress in all recommendations. It has met six recommendations, mostly met three recommendations and partly met three recommendations. Recommendation 1: The trust, with relevant commissioners, needs to ensure that it actively monitors the demand and capacity for children s services, including information about those patients it has not been able to admit. The trust has partly met this recommendation The trust has a system in place to manage demand and capacity on a daily basis, which is managed by clinical coordinators who collect data on referrals and admissions of patients. The trust uses a manual system for monitoring the status of tertiary referrals, as its information system is currently unable to record this data. The trust submitted a table that provided information on the tertiary referrals it received every day, which included information as to whether a patient had been offered a bed at the trust or not. This shows that the trust has a system in place through which it monitors and manages its capacity on a daily basis. However, at the time of our follow-up visit, the trust did not have a functioning monitoring arrangement in place to review demand and capacity for the trust at a management level. The trust was not yet able to produce, and show us, robust aggregated periodic reports that would enable it to actively monitor: to what extent it was able to admit its urgent referrals within 24 hours, and what was happening to emergency and urgent patients that it was unable to admit within 24 hours. The trust submitted a table to us containing data on its deflected patient activity (i.e. patients that it was unable to admit) between May 2009 and October The data in this table was incomplete, with no information available for 151 out of 360 patients. The trust acknowledged during our interviews that the information presented in this table was neither complete nor robust. The trust has tried to improve the accuracy of some of its data (for instance with regard to length of stay) by recruiting extra ward clerks. The trust has recently added a number of indicators to its performance report, aimed at ensuring that the board can better monitor issues with regard to the overall demand and capacity for its services. These include: delayed transfers into the trust, transfers out of the Emergency Department (ED) to other hospitals, bed occupancy in the Paediatric Intensive Care Unit (PICU), and overall bed occupancy. However, as at October 2009, no targets had been set and no data were reported, except for transfers out of ED to other hospitals, which was rated Birmingham Children s Hospital NHS Foundation Trust: Summary of progress with recommendations 4

6 red for the month of October 2009 (a total of 72 transfers). Therefore, at the time of our follow-up, the board did not have sufficient assurance that the actions taken by the trust had improved its ability to admit urgent patients. The trust s average monthly bed occupancy rate has remained above 100% (111% for October 2009). Some individual specialties (the liver unit and the consultants within neurosurgery) have developed their own monitoring arrangements for recording data on unmet demand, refused admissions and length of time from referral to admission. Their databases are updated by the admission secretary (for the liver unit) and the registrars (for neurosurgery) and are reviewed daily by the trust s patient access team. Within neurosurgery, three neurological conditions have been identified where the trust will always undertake a serious untoward incident (SUI) investigation if it turns away any patients with these conditions. The trust told us that no such SUIs have occurred since April Overall, although it has identified indicators that need to be collected and monitored at trust-level, we found that the trust has not as yet developed a system for collecting, aggregating and monitoring robust specialty and trust-wide data around unmet demand, including assessing delays in admissions. The trust was not able to produce reliable data to indicate what the need is and therefore still does not have a clear understanding of its unmet demand. There was a view from those involved in the data collection that the data they were collecting was still unreliable. The trust acknowledged that more work needs to be undertaken to review the way in which the clinical coordinators record data relating to transfers and admissions. In addition, we were told that more work will be done to ensure that data is captured correctly, analysed and reported, in order to regularly inform relevant managers and the board on whether the trust is meeting the demand for its tertiary services. Recommendation 2: The trust needs to review its strategies and policies to improve its management of admissions and beds, and ensure that staff throughout the trust keep to these. It also needs to work with its consultants to ensure that patients needing urgent care are admitted in a timely manner. The trust has mostly met this recommendation. This recommendation specifically related to neurosurgery and liver patients. The trust has identified a programme of work it needs to undertake to improve its bed management and patient flow. This is aimed at reducing the length of patients stay within the hospital, which is expected to result in reductions in the trust s bed occupancy rate, cancelled operations, and delays in admissions. Birmingham Children s Hospital NHS Foundation Trust: Summary of progress with recommendations 5

7 The trust has undertaken a number of initiatives to improve its management of admissions and beds. It is in the process of reviewing its bed management policy, and has revised its access policy for elective admissions. These are yet to be signed off. The trust has revised its escalation plan for capacity management, which includes instructions for escalation to senior managers when the hospital is under pressure. The trust s admission process for tertiary referrals is aimed at ensuring that patients are admitted in order of clinical priority. The trust told us that bed meetings are held daily and twice daily during periods of pressure. These meetings are supported by a Daily Capacity Management Tool, which is used to predict elective and emergency demand and to support decision making. If clinical coordinators are unable to admit a patient within 24 hours (this being the target for an urgent admission) this gets escalated to the Directorate Management Teams who work with clinicians to prioritise patients and to allocate beds appropriately. The trust told us that it has worked with staff to inform them, and obtain their support, about the changes in customs and practices needed to run the new bed management system. The trust is building up the skills that are required to put the policies into practice, and ensure that everybody knows their role and responsibilities. In addition, the trust was planning to move to an electronic version of its bed management system in January 2010, which includes up-to-date information about expected emergencies coming in, expected discharges, and TCIs (those waiting to come in), and will therefore be able to identify if there are sufficient beds available in the hospital. The trust submitted data to us (for the months of April 2009 to November 2009) for tertiary patients referred to the hospital that showed the time it had taken between when they were referred and when they had actually been admitted to the trust. This showed that, on average, 75% of tertiary surgery patients, and 72% of tertiary medical patients had been admitted within 24 hours of being referred. The data also showed that, on average, 9% of tertiary surgery patients, and 5% of tertiary medical patients that had been referred, ended up being admitted to other hospitals Within neurosurgery, protocols and guidance have been developed to agree how quickly patients with certain neurosurgical clinical conditions or criteria need to be admitted to the hospital. The first of these protocols is on Admission of Suspected Shunt Blockage/Malfunction/Infection (June 2009). The trust told us that further policies are being developed for the admission of patients with intracranial haematoma and infected or leaking meningocoele. The trust submitted data to us which showed that between April and August 2009, around 50% of urgent neurosurgical patients referred to the trust are admitted within four hours. However, the data also showed that there was a high percentage of patients (80% of patients during September and October 2009), for which no admission time was available. The trust stated that the majority of patients who had to wait longer than four hours were appropriately delayed for clinical reasons as these patients had required further observations and investigations before being admitted. Birmingham Children s Hospital NHS Foundation Trust: Summary of progress with recommendations 6

8 Staff from neurosurgery told us that since the introduction of the protocol, not one single patient has been refused, but some delays are still occurring in transferring patients from other hospitals into the trust. We found that, although there was a clear policy document, there was no evidence of an audit trail. Most staff told us that there has been more willingness by the trust (management as well as clinical coordinators) to work with consultants to try and ensure that patients needing urgent care are admitted in a timely manner. However, staff from the liver unit and neurosurgery stated that, although the majority of urgent patients referred to the trust get admitted, the trust still does not have effective and efficient arrangements in place to ensure that all urgent neurosurgical and liver cases are admitted within an appropriate timeframe. A senior executive of the trust raised concerns that some hospitals are now referring patients elsewhere due to the difficulties they have experienced with trying to admit their patients. This makes it difficult to determine what the unmet demand is for the trust. The trust acknowledges that, while it has undertaken a range of initiatives, further work is required to ensure it improves its ability to admit urgent patients. Despite the trust s efforts, we did not receive sufficient evidence that the trust has been able to significantly improve its ability to admit urgent neurosurgery and liver patients on time. Neurosurgery and liver consultants mentioned that it was still a struggle to admit patients on time, and provided examples where delays had occurred. Within the liver unit, 91 medical liver patients on the trust s priority list either had a delayed admission (81 patients were delayed with an average delay of 3.8 days), or were admitted to another hospital (10 patients) between December 2008 and December The efforts of the trust to admit patients are clearly hampered by the constant bed pressures within the trust, as a result of operating with high bed occupancy rates. In addition, neurosurgeons were concerned about the number of outliers (that is, neurosurgery patients being admitted to wards other than the neurosurgery ward). The trust told us that all neurosurgery elective patients are admitted to the speciality ward (Ward 10). The trust's bed policy supports speciality-based bed allocation in which the aim is to admit the child to the relevant specialty ward or repatriate the child at the earliest opportunity. With regards to neurosurgery, all children admitted as an emergency with brain tumours, or who require an external shunt, are admitted onto Ward 10. Patients with blocked shunts will, on occasion, be admitted to other surgical wards. During the period from 1 April to 30 November 2009, out of the 33 patients that should have been admitted directly to Ward 10, 23 were admitted directly to Ward 10 or the Neo-Natal Surgical Unit, whereas 10 patients were admitted to other wards and transferred to Ward 10 within two days. Birmingham Children s Hospital NHS Foundation Trust: Summary of progress with recommendations 7

9 Recommendation 3: The trust and commissioners of paediatric tertiary services must continue to work actively to manage the demand and provision of paediatric services at the trust. The trust has mostly met this recommendation. The trust has involved NHS Interim Management and Support (NHS IMAS) to better understand its capacity, demand and the complexities around case mix, patient flows and lengths of stay. NHS IMAS supports NHS organisations that ask for short or medium-term help in addressing specific issues or challenges. This work has identified 11 areas for action that have been linked to the trust s internal Transformation Team work programme, three of which are supported by ongoing input from IMAS. Furthermore, it has helped the trust in developing tools to predict demand and capacity and ensure that this is included in planning. The trust has worked together effectively with the clinical leads for interventional radiology, craniofacial surgery and renal transplants to assess the demand for their service and has increased their capacity (including extra theatre sessions) to deliver the service. There are regular meetings between the trust and clinical leads to review the demand for the service and discuss its future development. Both the Specialist Commissioning Team for West Midlands and the National Commissioning Group were satisfied with the progress the trust had made in addressing the issues in the Healthcare Commission s intervention report, and mentioned that the trust engaged regularly and openly with them on its progress in implementing the action plan and its plans for developing the service. We were not told of any specific examples of where these initiatives had already resulted in significant improvements in the trust s overall capacity. The trust does not produce data to assess if its initiatives have had an impact on improving its capacity. Furthermore, the trust acknowledges that more work is particularly required to come to an agreement in terms of the way forward for neurosurgery. The Specialist Commissioning Team for West Midlands commissioned an external, independent review of capacity and case mix in neurosurgery in September The findings of the review had not been released at the time of our visit. Neurosurgery consultants told us that the number of beds on Ward 10 was still not sufficient for the number of neurosurgical patients that need to be admitted. Bed capacity has remained constant with 14 beds being available during the week, which reduces to 12 for the weekends. As such, the number of neurosurgery outliers remains a significant issue for the neurosurgical consultants. This is a concern particularly when conditions such as blocked shunts have to be looked after on other wards. The Paediatric Early Warning System (PEWS) chart used on other wards does not include sufficient neurological observations. At present, the neurological observation chart used on Ward 10 is not used for all neurosurgical patients on other wards, as it first needs to be specifically prescribed for in the patient s Birmingham Children s Hospital NHS Foundation Trust: Summary of progress with recommendations 8

10 treatment plan. Neurosurgery consultants are concerned that, because these charts are not automatically used for all neurosurgery outliers, some of these patients will not have the appropriate neurological observations undertaken from the moment they arrive into the hospital. A robust system for monitoring neurosurgical patients should be implemented, although ideally these patients should be on the neurosurgical ward. The trust admitted that it needed to do more work to resolve the challenges of capacity and demand, but that great steps have been taken in getting that understanding, and working with commissioners to develop a longer-term strategy. The trust has started to think about this and is in the process of commissioning work to develop options for an overarching long-term strategy with regard to its demand and capacity problems. More information on how the trust has worked with its commissioners on its capacity is included under recommendation 12. Recommendation 4: The trust needs to review the way it organises capacity and prioritises cases within theatres, to ensure that patients requiring urgent and emergency surgery gain access to theatres in a timely manner. The trust has partly met this recommendation. The results of the work undertaken by NHS IMAS supported the findings from our intervention report, as they stated that the trust has insufficient theatre and day case capacity to work in-hours and limited dedicated time for urgent cases. One of its recommendations included building a dedicated theatre day case unit and considering the scope for providing urgent slots or lists. We heard that the current theatre lists are 94% used and it was doubtful that theatre efficiency could be improved further. The trust told us that they have identified a need for a further 40 theatre sessions to be staffed and funded a week on a regular basis. The trust has put additional evenings and weekend sessions in place to reduce an existing backlog for non-urgent patients requiring elective surgery that had been displaced due to emergency work. The trust reported that it expects to deliver an additional 290 theatre sessions in 2009/10, compared to 2008/09. The only way of trying to expand further, is by moving activity off site and/or increasing the number of theatres, all of which would take time to achieve. The trust is aware that it needs to increase its overall theatre capacity, and is looking at various options, which include: To put in three or four additional theatres by building a dedicated stand alone day case theatre area. To create an additional theatre through internal reorganisation. To put in a modular theatre by the end of Birmingham Children s Hospital NHS Foundation Trust: Summary of progress with recommendations 9

11 We were told that that because of design, planning, procurement and construction time it would take up to two years before these plans would result in an increase in actual theatre space. To ensure that all patients who need urgent and emergency surgery have timely access to theatres, other surgery cases have to be cancelled. The number of cancelled operations (cumulative performance) in the period April to October 2009 was worse than the same period in the previous two years, and consistently breached the trust s set target for cancelled operations. However, the trust s performance has recently improved from 33 cancellations during July 2009 to 11 cancellations in November Staff in most specialties told us that there has been an improvement in the way theatre managers have responded when requests are being put forward for urgent surgery, which has resulted in some improvement in access. The trust managed to achieve a sustainable increase in elective capacity for interventional radiology by increasing the elective theatre sessions from one to two sessions for interventional radiology (with a third planned for the end of 2009/10). The access to theatre for craniofacial surgery increased from 2.3 to 3.75 sessions a week. The Operational Policy for the Management of Patients requiring Renal Transplantation (June 2009) states that every effort will be made to carry out transplant within working hours subject to cross matching time required. Elective trust theatre capacity may be cancelled to accommodate renal transplants as per the theatre transplant policy. However, some staff told us that access to theatres has remained difficult, particularly for urgent, non life-threatening, neurosurgery and liver cases. As a result, emergency liver surgery has to be undertaken out-of-hours. Access to theatres is a particular issue for neurosurgery, as almost half of its activity is classified as emergency (46% of total activity during 2008/09), compared to only 23% for all other specialties in the trust (2008/09). The trust has identified a programme of work aimed at addressing the difficulty experienced by the liver team in getting access to emergency theatres, as well as improving the management of urgent cases. We found, that there has been no expansion to the theatre footprint (the number of theatres) and no real reorganisation in the way the trust organises its emergency lists. As a result, access to emergency theatres is still a significant problem. We were told that non-emergency cases are still frequently done on the emergency theatre list, which starts after 1.30pm. Plans are being developed, but the situation on the ground has not yet improved for neurosurgery and urgent or emergency liver surgery. The trust has started to put together a long-term plan to expand the theatres to get a second dedicated list for emergency and urgent operations (CEPOD list). However, no immediate solutions are in place to significantly increase theatre capacity. Birmingham Children s Hospital NHS Foundation Trust: Summary of progress with recommendations 10

12 Even though these difficulties have resulted in delays in patients being treated, we did not hear of any incidents where patients had been put at risk of harm, nor were we informed of cases where patients needed to be transferred to other hospitals, as a result of delay in access to theatres. Recommendation 5: The trust needs to urgently agree a clear plan to ensure that it has the capacity and systems in place to provide sufficient and timely access to elective and emergency/out-of-hours interventional radiology. The trust has met this recommendation. The fluoroscopy room in the radiology department (Room 4) has been refurbished with equipment capable of both conventional fluoroscopy and interventional radiology procedures. Air-conditioning was upgraded to theatre standard and an adjacent anaesthetic room constructed. As such, an additional weekly elective interventional radiology session has been established on a Thursday morning since September A further (third) elective session is expected to be established on Tuesday afternoons by the end of the financial year (2009/10). This has enabled the interventional radiologists to expand the services and procedures they offer. In order to establish additional sessions, the service level agreement (SLA) has been renegotiated to support an increase from one to three elective sessions a week, and allow time for consultants from UHB to participate in multidisciplinary team meetings and support professional activity such as clinical governance and research. SLAs for these services detail the responsibilities and requirements for both trusts. UHB has been able to support the expansion in sessions by the recent recruitment of two additional interventional radiology consultants (increasing the number to eight) and the trust has recruited and trained additional theatre staff. The interventional radiology teams from both the trust and UHB have worked collaboratively to produce three operational policies for elective, urgent and emergency cases, which provide a robust process for requesting interventional radiology. The policy states that any urgent interventional radiology cases need to be carried out within 48 hours. Responsibility for coordinating the scheduling of interventional radiology has been recently transferred from a UHB secretary to a dedicated interventional radiology coordinator from the trust s radiology department. The interventional radiology coordinator is now able to: effectively manage the scheduling of procedures and the interventional radiology waiting list; provide a single point of contact for all referring clinicians at the trust and the UHB interventional radiology team; and support the process for arranging urgent or emergency interventional radiology cases. The current interventional radiology SLA states that UHB does not provide an out- Birmingham Children s Hospital NHS Foundation Trust: Summary of progress with recommendations 11

13 of-hours service. However, the UHB interventional radiologists will attend an emergency case. Six of eight consultants are paediatrically trained, which means for three-quarters of the time there will be emergency interventional radiology cover available out-of-hours. When this is not available, we were told that other options will be available. The trust told us the requirement for out-of-hours emergency interventional radiology is very low. The trust reported that the clinicians from the clinical specialties most involved with the interventional radiology service have confirmed that, since March 2009, no open procedures have been performed when interventional radiology would have been more appropriate. Furthermore, the waiting time for interventional radiology has decreased from over a year to around six to 10 weeks. We were told that the trust will do further work to reduce the amount of out-of-hours work and they are trying to increase the number of theatre nurses who can support the interventional radiology work. The actions described above have encouraged development of an open dialogue between consultants and managers at the trust and at UHB. Improvements in regular communication include the quarterly meetings to monitor and discuss the current SLA and any required amendments. The quarterly SLA monitoring meetings have been supplemented by weekly exchanges of s and telephone calls to arrange and confirm procedures and continual improvements to the service. Recommendation 6: The trust must ensure that it provides, for urgent renal transplants and neurosurgery, an appropriate and sustainable level of support within theatres at all times. This needs to be informed by discussions with the surgeons involved about the standards of support required from theatre staff. The trust has met this recommendation, with further work ongoing. Renal transplants The renal transplant process has been documented and communicated to all staff. We were told that a 12-month arrangement had been put in place for two UHB theatre nurses to come to the trust and support its theatre staff during renal transplants. In addition, the trust has sent about 20 theatre nurses to UHB since May 2009, to attend living donor transplant sessions. This has provided the trust s staff with an opportunity to better familiarise themselves with the procedures and equipment involved in such specific procedures, thereby building the knowledge within the trust s transplant team. We were told that the out-of-hours cover is now fully provided by scrub nurses from the trust itself. A Renal Transplant Scrub Practitioner Competency Document for experienced Practitioners has been jointly developed and implemented by the trust and UHB. So far, three staff members have achieved 100% of their required formal education and training, and have a record of cases complete. Birmingham Children s Hospital NHS Foundation Trust: Summary of progress with recommendations 12

14 The plans that have been developed with the renal transplant consultants for a joint programme will consist of two consultants within the trust being trained to undertake renal transplant. As these consultants are based at the trust, they will be able to build strong working relationships with the theatre nurses scrubbing for renal transplants, in order to ensure that the nurses have the skills and experience expected of them. Neurosurgery The trust has developed a Neuro/craniofacial Scrub Practitioner Competency Document for Experienced Practitioners. The trust told us that relevant theatre staff have been working through this document and it reported in January 2010 that five staff members had achieved between 80% and100% of their required formal education and training, of which four had their record of cases complete. Two other staff members are due to start the competency programme, one of which has returned from maternity leave (January 2010) and one who recently started (December 2009). A list of procedures has been identified that should not be carried out without a specialist neuro scrub nurse. If a specialist neuro scrub nurse cannot be identified, a Neuro Staff Scheduling protocol has been agreed to ensure that the theatre coordinator will inform the neurosurgeon on time. Until November 2009, only one case had to be cancelled because no specialist neuro scrub nurse was available at the time. Overall, the neurosurgeons did not raise any concerns with regard to the theatre staff they have worked with since March Recommendation 7: There should be clarity between the trust, UHB and UHB consultants regarding what the UHB consultants will provide in terms of the specialist paediatric service, and what standard of support and equipment these consultants need in order to enable them to provide that service. This recommendation specifically related to interventional radiology, neurosurgery and renal transplants. It has been met. Interventional radiology Interventional radiologists were satisfied that the issues with regard to equipment have been addressed and they told us that, whenever they have needed equipment, the trust has bought it. The consultants had worked together with the trust to agree on an inventory, which includes the more common equipment needed for most cases. The trust reported that Room 4 has been stocked with all the required consumables, including catheters, guide wires, access sets, emobilisation materials, stents etc. In addition, it plans to install haemodynamic equipment in Room 4 as a back-up facility for the angio theatre. On occasion, consultants still need to bring their own specialist equipment for the more complicated surgical procedures. As these cases are low in volume, it would not make economical sense for the trust to have this equipment on site. Birmingham Children s Hospital NHS Foundation Trust: Summary of progress with recommendations 13

15 Renal transplants Renal transplant consultants were satisfied that the issues with regard to equipment have been addressed. The trust reported that it had completed a full review of all theatre equipment, established a renal trolley within theatre and resolved the issue of availability of equipment. There is now a process in place for a twice yearly joint review of equipment. Neurosurgery The trust told us that the theatre manager had discussed the issue with the scrub nurse and team leader. As a result it bought two additional drills and additional trays, to cover for the increased use of neuro/cranio equipment in craniofacial. This has been ordered and received. Because of the theoretical risk of variant CJD (Creutzfeldt-Jakob disease) infection, a decision has been made nationally to ensure that children born after 1997 are not exposed to surgical equipment that may have been exposed to neural tissue of patients born before The trust planned to implement this in January As a consequence, it will have doubled all its neurosurgery equipment by January Recommendation 8: The trust needs to review urgently the arrangements for Hospital at Night with senior clinical staff, to ensure that any outstanding concerns have been properly addressed. The trust has partly met this recommendation. This recommendation was specified in the intervention mainly due to concerns in relation to liver patients. Liver consultants were of the opinion that registrars who were not trained in liver cases would not be familiar with these (very specific) conditions. Since the intervention report was published in March 2009, the trust acknowledged that the options for a liver Hospital at Night service needed further examination. From the surgical side, the issue with regard to liver patients has been resolved with the recruitment of two additional posts and one fellow from the Royal College of Surgeons for one year. Most of the liver patients are taken as surgical patients, with liver transplant patients being categorised as surgical patients for the first three months. The trust is monitoring if there are any incidents arising from Hospital at Night and has not seen any particular patterns. It reports that there have been two incidents where patients should have been escalated to a consultant in a timely manner. These incidents have been investigated, and policies have been changed and training provided as a result. Overall, the question of medical cover at night for paediatric liver patients remains outstanding. The trust told us that it was planning to commission an independent Birmingham Children s Hospital NHS Foundation Trust: Summary of progress with recommendations 14

16 external review of the Hospital at Night model. A worked-up assessment and recommendations to the Executive (and then the Board) was expected by February 2010, with a decision to be reached in March Recommendation 9: The trust must agree, together with relevant consultants and its commissioners, a clear plan setting out actions being taken to ensure that craniofacial patients will be treated at the appropriate age and that any delays will be minimised. This recommendation has been met. Staff told us that the trust s management and the clinical lead for craniofacial surgery had worked together closely to provide an accurate costing of the service and assess the ongoing capacity needs. The trust reported that the waiting list had been assessed and validated to determine the actual numbers and length of wait. This has informed a workforce and capacity plan. Based on this, the National Commissioning Group agreed to support the trust with additional non-recurrent funding in order to clear the backlog of 18 patients. The trust increased elective theatre access from 2.5 to 3.75 sessions in June 2009 and took on a locum plastic surgeon (0.5 plastics/0.5 maxillo) in July 2009 to support the increase in activity. As a result, the backlog of patients has now been reduced to three (as at 18 December 2009), which is ahead of the trajectory agreed with the National Commissioning Group. In March 2009, the Healthcare Commission reported that it was concerned that delays in access to treatment for craniofacial patients was a particular problem for those patients who relied on operations being done at an early age to ensure the best possible outcome. Since this report was published, the age at which craniofacial operations take place in the trust has lowered, but it is too early to draw any conclusions with regard to this. The trust submitted a bid to the National Commissioning Team for craniofacial services in August 2009 as part of the development of a national tariff for craniofacial services. Due to complexities and other issues, the development of the tariff was not taken forward. Discussions between the National Commissioning Team and the trust for the 2010/11 contract have not yet been concluded. Birmingham Children s Hospital NHS Foundation Trust: Summary of progress with recommendations 15

17 Recommendation 10: The trust must develop better, formal, communication with UHB consultants undertaking work at the trust, to ensure that any concerns are identified and addressed in a timely manner, and that the views of these consultants are formally incorporated into the trust s arrangements for governance. This recommendation has been mostly met. The trust appointed a new (interim) chief executive officer (CEO) in March 2009 (made substantive in June 2009), a new (interim) medical director in September 2009 (made substantive in October 2009), and a new (interim) chief operating officer (COO) in March 2009 (made substantive in November 2009). The staff we spoke to told us that the new management has put a lot of effort into improving its engagement with both UHB and its consultants. The work to address the issues identified within the intervention report has encouraged development of an open and constructive dialogue between consultants and managers at the trust and at UHB. As a result, staff told us that relationships and communication between the trust and UHB has significantly improved at all levels. Commissioners are satisfied that there are no concerns around communication with consultants at the trust and at UHB. Single points of contact (consultants) have been identified at UHB for the various specialties. UHB consultants told us that they are now much clearer on the protocols for raising concerns, and most felt confident that concerns are being listened to and acted upon by managers within the trust. Some of the staff we spoke to felt that the trust could further improve the way it involves those who have raised an incident into any investigation, as well as providing feedback about its outcomes. The CEO and (interim) COO of the trust provided an opportunity to meet with clinicians at UHB in August and November, to have an informal review of the action plan and address any residual clinical concerns. In addition, clinicians were invited to come to a trust board meeting to give their perspective on how things were progressing. The trust reported that specific focus over the past few months has been given to improving relationships between the renal transplant surgeons at UHB and the nephrologists at the trust. This has been facilitated by the chief medical officers at the trust and UHB and NHS IMAS, and staff told us that working relationships and team working has improved as a result. SLAs that have been agreed between the trusts include arrangements for participation of UHB consultants in clinical governance activity. For instance, the neurosurgery SLA states that UHB will commit to providing two neurosurgeons to multidisciplinary team meetings. The engagement with neurosurgeons has not been effective so far and there is a marked difference of opinion as to what the neurosurgeons tell us compared to what the trust report. The trust has indicated that the medical director will meet with the neurosurgeons on a monthly basis to establish better communication. Birmingham Children s Hospital NHS Foundation Trust: Summary of progress with recommendations 16

18 Leadership Consultants had raised concerns with the trust in September 2008 about a lack of leadership on Ward 10, and the impact that this could have on safety. Ward 10 is the neurosurgical ward to which patients return after craniofacial surgery. Before the concerns were raised in September 2008, the trust had already undertaken a number of actions, which included undertaking a risk assessment and a change in ward manager in May Since the Healthcare Commission published its report in March 2009, the trust appointed a permanent ward manager in June 2009, who had previously worked as a clinical nurse specialist in neurosurgery at UHB. She is supported by a nurse manager. We were told that the new ward manager had been able to develop good relationships and communications with the neurosurgery consultants. In addition, teamwork on the ward has improved, sickness levels have gone down to 2.9% (from over 10% previously), and retention of staff has also improved. The trust reported that 14 new staff had started on the ward (out of a total complement of 34), which means that the ward is now up to establishment. The trust conducted a competency-based assessment of staff before October 2009 to identify the training needs of staff. To increase the neurological knowledge of the newly recruited staff, the trust has organised daily half-hourly ward teaching sessions on specific topics (one topic a week), which all staff are required to attend. The trust has also brought in 50 hours of neurosurgical clinical nurse specialist time from UHB to carry out training at the trust, which was about to start when we visited. The trust should continue to support the implementation of the training programme on the ward. Recommendation 11: Job plans that take account of the time spent by UHB consultants at the trust need to be developed by UHB. The trust needs to clarify and agree with UHB the level of input it requires from UHB staff, including time to enable more involvement of consultants in the clinical governance and management structures at the trust. Once the job plans are developed, the trust should be involved in the appraisals and professional development of these consultants. This recommendation has been met. The trust has held separate meetings with senior managers and clinicians to try to reconstruct what the SLAs between the trust and UHB should be. SLAs for all joint services provided in partnership with UHB were signed by both trusts on 30 June These are underpinned by operational policies and procedures, and include arrangements for participation in clinical governance activity. For instance, the neurosurgery SLA states that UHB will commit to providing two neurosurgeons to multidisciplinary team meetings. Birmingham Children s Hospital NHS Foundation Trust: Summary of progress with recommendations 17

19 The SLAs are subject to regular review meetings, which will ensure ongoing engagement between the two organisations to discuss changes that need to be made and the further development of the service. For instance, the interventional radiology SLA states that a quarterly BCH/UHB interventional radiology monitoring meeting will be arranged on site at BCH. Standing agenda items include: Activity. Operational issues. Review of progress against the trust/uhb action plan. Strategic developments. Risk/governance issues, including a review of any complaints and clinical incidents. Overall, we found that the trust has clarified and agreed with UHB the level of input it requires from UHB staff. We have been told by staff that job plans have been developed that take account of the time spent by UHB consultants at the trust. Time has been allocated or dedicated in the job plans for consultants to be more involved in clinical governance. There are plans in place for joint appraisals, the mechanism of which is yet to be agreed with the trust. Recommendation 12: The trust and UHB, with the support of the commissioners, must agree on and implement a model of care delivering high-quality paediatric services, in line with the requirements of Monitor, the independent regulator of foundation trusts. Monitor must ensure that both trusts play their part in implementing this new model of care. This recommendation has been met. However, further work still needs to be undertaken with commissioners before a final model of care for paediatrics across the West Midlands can be agreed and implemented. Monitor met with the trust and UHB to agree on a set of outcomes that both organisations would sign up to in order to ensure continued delivery of safe and sustainable services. Actions to deliver these outcomes formed an essential part of the master action plan, which was agreed by all major stakeholders. The implementation of the action plan was monitored by a joint trust/uhb Programme Board, which reports to the Tertiary Paediatric Clinical Performance Task Force Group on a monthly basis. This group consists of representatives of West Midlands Specialist Commissioning Group, Heart of Birmingham Teaching PCT, and the National Commissioning Group. In August 2009, the Task Force Group was satisfied that all actions had been taken to address the immediate operational risks identified at the time of the review. Monitor was kept informed about the progress made in implementing the action plan through monthly exception reports from the trust, and monthly discussions with the trust and the West Midlands Specialist Commissioning Group. Birmingham Children s Hospital NHS Foundation Trust: Summary of progress with recommendations 18

20 The West Midlands Specialist Commissioning Group held a three-day strategic commissioning event on October to review the model of care for tertiary paediatric surgical services. More than 120 key stakeholders from across the West Midlands health economy participated, including over 50 clinicians. The aim of the event was to agree a way forward for developing a regional strategy for children that need surgery. Following the consensus reached at this event, the West Midlands Specialist Commissioning Group has been tasked with developing a joint commissioning strategy for the West Midlands. Over the last few months, the trust has engaged with its clinical leads and clinicians to discuss options available for the future development of each of the services. For instance, both trusts have worked together to agree on a joint model of care for the renal transplant work, which aims to establish a transplant service led by the trust s consultants, with support from UHB. As a result of these discussions, most staff that we spoke to were confident that the trust was committed to the further development of their service. However, we were told that more work was still required by the trust to come to an understanding and agreement with regard to the specialties of neurosurgery and liver. This work will need to be further informed by the outcomes of the strategic commissioning event held in October 2009, the trust s long-term strategy, and external factors and developments such as the National Commissioning Group s consultation on a set of standards for safe and sustainable paediatric neurosurgery. Birmingham Children s Hospital NHS Foundation Trust: Summary of progress with recommendations 19

21 Conclusions We have noted the actions taken to implement the recommendations identified in the intervention report of March As such, we conclude that the trust has made considerable progress against most of these recommendations. The trust has worked together extensively with NHS IMAS, which resulted in a better understanding the issues and challenges relating to its capacity and demand. The trust has effectively engaged with its clinical leads for interventional radiology, craniofacial surgery and renal transplants to agree the level of input it requires from UHB consultants, and ensure these consultants have the equipment and specialist theatre staff available to enable them to provide that service. Furthermore, the trust has increased the capacity for these specialties (including extra theatre sessions) to deliver the service. As a result of the work undertaken by the trust s new management, most of the staff we spoke to told us that relationships and communication between the trust and UHB have improved significantly at all levels. However, we have also identified a number of areas where more progress is needed. We found that the trust had not as yet developed a system for collecting, aggregating and monitoring robust specialty and trust-wide data around unmet demand, including assessing delays in admissions. More work is also still required to ensure that significant improvements in access to theatre are being made, and in particular for urgent, non life-threatening, neurosurgery and liver cases. The question of medical cover at night for paediatric liver patients also remained outstanding at the time of our follow up visit to the trust. Where the intervention report identified areas for further improvement, the trust was, in most cases, able to provide us with actions it was already planning to undertake to ensure improvement. In summary, we agree that there is sufficient evidence that the recommendations have either been complied with, or that actions are in place to ensure improvement. The remaining areas of required improvement will be monitored by the regional operational team. Birmingham Children s Hospital NHS Foundation Trust: Summary of progress with recommendations 20

22 Care Quality Commission 2010 Published May 2010 This document may be reproduced in whole or in part in any format or medium for non-commercial purposes, provided that it is reproduced accurately and not used in a derogatory manner or in a misleading context. The source should be acknowledged, by showing the document title and Care Quality Commission 2010.

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