Update on University NHS Foundation Trust

Background When the Keogh Review was published on 16 July last year, Colchester Hospital University NHS Foundation Trust (the Trust) was one of only three of the 14 “Keogh Trusts” not put into special measures. However, as a result of the publication on 5 November of a Care Quality Commission (CQC) inspection of the Trust’s cancer services and on the recommendation of Professor Mike Richards, the Chief Inspector of , Monitor put the Trust into special measures on 14 November “to ensure all its patients receive good quality care”. The Trust remains in special measures.

On 14 January Monitor announced the appointment of Mark Davies, who has previously been the Chief Executive of seven NHS trusts, to the role of Improvement Director to support the Trust. On 3 February the regulator announced that the Royal Marsden, an NHS foundation Trust with a world-leading reputation for cancer services, would offer the Trust support and expertise in delivering improvements to the cancer pathway.

In January, the Trust’s Board of Directors established a Turnaround Programme Board, chaired by the Chief Executive, to address key areas requiring fast improvements or focus, including cancer, emergency care and 18 weeks Referral To Treatment. The Trust has been focusing on developing and implementing action plans designed to ensure that every patient receives good quality care.

The Turnaround Programme is supported by the Programme Management Office (PMO) which has been established to ensure the delivery of sustainable improvements in systems and processes to deliver improved patient care. Monitor had identified that the Trust should implement stronger programme management arrangements.

The Trust’s vision, purpose and strategic objectives for 2014/14 are set out in Attachment A.

The Keogh Review The Keogh Review, published 12 months ago, recognised there had been a number of improvements since a change of leadership at the Trust in 2010 but there was still more work to do. It called for the Trust to speed up the implementation of an action plan that had been finalised a fortnight earlier, to address the areas identified for improvement and to ensure consistency of care across all areas of the organisation.

The Keogh Review referred to “great examples of excellent care being delivered to patients,” said the “workforce is committed, loyal, passionate, caring and motivated” and “Across a variety of wards, patients provided positive feedback and were pleased with the quality of care.”

Key issues identified in the action plan included:

 quality focus – quality focus in the Trust needed further development and an underpinning strategy

 clinical leadership – the Trust needed to empower clinical leadership through an improved governance and organisational structure

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 deteriorating patient – processes to recognise and escalate deteriorating patients were not operating as effectively as they could

 communication and engagement with staff – the Trust needed to continue to listen to staff

 staffing and skill mix – nurse staffing levels and skill mix review needed to be regularised

 complaints – complaints management processes needed urgent improvement.

The Trust continued to implement its Keogh Action Plan but its focus changed as a result of the CQC inspection of cancer services and its subsequent report, published in November last year. However, in order to regain focus, the action plan became one of the work streams when the Trust’s Turnaround Programme was established in January. The Chief Executive has recently become the executive lead for the improvement programme.

On 6 February, the day after the Trust last appeared before the HOSC, a panel of experts led by the Medical Director of NHS England (Midlands and East) visited the Trust at the request of Monitor to review progress against the Keogh action plan. Its report was published on 12 March (Appendix B).

The panel reported that there had been improvements since June but “the focus on quality must remain a priority”. In 26 out of 33 areas, there had been improvements but the panel said there was still more work to do before these actions could be regarded as fully implemented. These areas included the care of deteriorating patients, infection rates after surgery, improving the complaints process, staffing levels and skill mix, and the availability of hospital porters.

There was either still significant concerns or limited or no evidence that improvements had started in six area, including the development of a quality focus, compliance with mandatory training and support for junior doctors. One area, relating to escorting patients to the radiology department for diagnostic tests, had been fully implemented.

The Trust’s Keogh action plan is regularly updated and, after being reviewed and signed off by Monitor, is published on the Trust website (www.colchesterhopsital.nhs.uk) and NHS Choices (www.nhs.uk). The latest version, dated 30 May, is attached (Appendix C).

In her report to the Board of Directors meeting on 12 June, Trust Chief Executive Dr Lucy Moore said she expects “progress at pace” against outstanding issues.

Cancer care The Trust developed a comprehensive action plan to improve cancer services in response to last November’s CQC report and publication the following month by NHS England of its Report into the Immediate Review of Cancer Services at Colchester Hospital University NHS Foundation Trust.

This plan, which was approved by Monitor, is constantly evolving and a summary version of it is regularly published on the Trust website and NHS Choices. The latest version, dated 31 May, is attached (Appendix D).

Even before the CQC report was published, the Trust recognised and accepted that it needed to improve its cancer performance. As well as having a detailed plan, the Trust also has expert support from the Royal Marsden, which we welcome and are finding extremely helpful.

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The Cancer Action Plan is regularly reviewed, including at the weekly meetings of the Cancer Services Steering Group, whose executive lead is the Medical Director and which reports to the Turnaround Programme Board. The group’s programme director is the Trust’s first Cancer Programme Director, a very experienced cancer manager appointed from outside the Trust who is an expert in the interpretation of national cancer standards guidance.

Among the improvements that have already been made are:

 a review of workloads, including a full workforce review, to ensure staff have the resources they need, which has resulted in the recruitment of additional staff, eg an additional consultant urological surgeon with extra registrar/associate specialist support and 4.26 extra Multidisciplinary Team (MDT) co-ordinators. However, the Trust has advertised a second time for a Cancer Lead Nurse (interview date: 30 June) and has also, so far, been unable to recruit to some additional clinical nurse specialist posts despite multiple advertisements

 more and better training. For example, a programme of regular and continuous training has been developed for MDT co-ordinators

 the implementation of a new cancer information system (the nationally recognised Somerset Cancer Registry), which went live on 6 March. It means key information is recorded on a single system rather than on multiple data bases

 the Cancer Committee has been regenerated into the Cancer Board with clear terms of reference and accountability. Its members include a GP who is the cancer lead for North East Clinical Commissioning Group (CCG) and the CEO of Healthwatch Essex

 a review of every aspect of diagnosis, treatment and care to ensure the Trust is fully implementing national standards

 making sure all staff fully understand their roles and that there are clear lines of accountability

Five of the six cancer pathways that the NHS England report from December last year said were not safe have been reviewed again, and have all been found to be safe by external peer review panels. These panels included a consultant of the same specialty, a clinical nurse specialist, a manager and in some cases North East Essex CCG’s GP Cancer Lead and the Medical Director of NHS England’s Local Area Team.

As with the Keogh Action Plan, Trust Chief Executive Dr Moore expects “progress at pace” against the outstanding issues in the Cancer Action Plan.

A £25m purpose-built, state-of-the-art radiotherapy centre at Colchester General Hospital started to treat patients on 9 June. Radiotherapy at Essex County Hospital will cease in September. In early October, the Trust’s cancer patient beds are also scheduled to transfer to Colchester General Hospital.

The Trust has also initiated a retrospective review of more than 1,000 patients treated between April 2010 and November 2013. The objective is to investigate the extent of data inaccuracies and the impact on clinical care through a transparent audit process, take necessary remedial action to ensure accurate reporting and improved systems of care, and provide assurance to the public and stakeholders. It is anticipated the review will be published in October.

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This review is one of the work steams of the Trust’s Turnaround Programme. The Trust’s Medical Director is the executive lead of the Retrospective Cancer Review Steering Group which meets weekly.

Monitor has received a draft copy of an independent investigation into how the Trust responded to concerns about cancer waiting times. The appropriate due process, which includes legal advice, is being followed ahead of the report being published by the Trust. A criminal investigation by Essex Police into the alleged manipulation of cancer waiting lists is ongoing.

Leadership On 19 May Dr Sally Irvine, who has been Trust Chair since August 2010, announced her intention to step down later this year. The Trust has just appointed a specialist executive search and selection company to help with the recruitment of a new Chair who will play a role in the appointment of a substantive Chief Executive and other substantive executive director posts.

Dr Lucy Moore became interim Chief Executive on 27 May in succession to Kim Hodgson, who had also been an interim Chief Executive following the departure of Dr Gordon Coutts, the Trust’s last substantive Chief Executive, at the end of 2013. A doctor by training, Dr Moore had been an acute hospital Trust Chief Executive from 2004 to 2012 and had already been working at the Trust since January this year to support the Medical Director and the four Divisional Directors. The latter were new posts, which were advertised nationally, to help the Trust fulfil its vision of creating a clinically-led organisation.

On 9 June, the Trust announced that Ian O’Connor, who has been interim Director of Finance since 3 February, will step down at the end of this month (July). The Trust also currently has an interim Chief Operating Officer (Evelyn Barker), an interim Director of Human Resources (Lynn Lane) and an interim Director of Corporate Affairs (Helen Robinson).

Following elections, there have also been significant changes to the Trust’s Council of Governors. Eight new public governors and five new staff governors joined the Council in April.

Recruitment In recent months, the Trust has successfully recruited to some hard-to-fill consultant posts, such as a consultant breast radiologist, and has also appointed to some additional consultant posts which have been created, such as in urology, oncology and colorectal surgery.

However, in line with the NHS as a whole, the Trust has encountered difficulties in recruiting to some specialties, such as emergency medicine, Emergency Assessment Unit and dermatology and has therefore on some occasions provided cover by going to commercial agencies, which has added to cost pressures on the Trust. The Trust is working actively to reduce expenditure in this area.

In the first half of 2013, the Trust started to increase the size of its nursing workforce. By 31 December that year, there were 85 more qualified frontline nurses (FTE) in post than there had been on 1 April, partly as a result of a successful recruitment drive in Spain. In March this year, we announced that we would be recruiting an additional 31 nurses, including 10 new posts on the Stroke Unit and the same number in the Emergency Department (A&E). These 31 posts also include an Associate Director of Nursing and Allied Health Professionals for each of the Trust’s four divisions in order to provide them with nursing leadership. They will be responsible for patient safety, patient experience and clinical effectiveness within their divisions.

With approximately 1,500 staff in the nursing workforce, recruitment takes place all-year round. It is proving more difficult to recruit to some specialties than others, including care of the elderly, stroke and the Emergency Department. Clearly, some of this difficulty is the direct result of expanding the workforce in those areas. In the interim we are using bank and agency staff

4 through our contract with NHS Professionals, a specialist organisation within the NHS recruiting and supplying temporary doctors, nurses, and corporate staff. As already stated, the Trust has also had to re-advertise for a Lead Cancer Nurse after failing to recruit at the first attempt.

The Trust is currently reviewing its nurse recruitment, which includes investigating the use of social media and considering another overseas recruitment initiative to enable us to deliver our increased workforce numbers.

There is some evidence to suggest that the damage caused to the Trust’s reputation by recent events, principally the Keogh Review and cancer issues, has had a negative impact on recruitment into some teams, such as nutrition and dietetics, and nursing.

Mortality There have been reductions in both the main mortality indicators – the Hospital Standardised Mortality Ratio (HSMR), which measures deaths that occur only in our hospitals (Colchester General Hospital and Essex County Hospital), and the Summary Hospital-level Mortality Indicator (SHMI), which includes deaths within 30 days of discharge from hospital.

The final HSMR figures for 2013/14 will not be published until the autumn but the Trust is anticipating a “score” of 100 (100 = national average) compared with 105.5 for 2012/13, therefore continuing the trend since 2010/11 of the Trust having an HSMR score “within the expected range”.

There is a significant time-lag before SHMI data is published but this too is showing a downward trend. The latest score is for October 2012 to September 2013 and was 111.5 (100 = national average), which is within the expected range. Further reduction is expected. This figure compares with 114.6 for July 2012 to June 2013, 115.51 for April 2012 to March 2013 and 118.32 for January 2012 to December 2012. A report about SHMI published on 30 April (2014) by the Health & Social Care Information Centre stated: “Colchester Hospital University NHS Foundation Trust and Wye Valley NHS Trust were identified as higher than expected repeat outliers in the previous edition of this report, but are not identified as higher than expected repeat outliers in this report.”

A consistently high SHMI was the reason why in early 2013 Professor Sir Bruce Keogh, NHS Medical Director for England, was asked to look at the quality of care and treatment provided by the Trust and 13 others.

North East Essex CCG has publicly stated that the reduction in both mortality indicators may reflect improvements in documentation at the Trust, enhanced consultant involvement in accident and emergency and steady improvement in the provision of end of life care in the community. A multi-agency group, including the Trust, has developed a joint action plan to improve communication and the care provided to patients at the end of life.

Because SHMI includes deaths within 30 days of discharge from hospital, the Trust continues to work with partner organisations, such as the CCG, Anglian Community Enterprise, the East of England Ambulance Service and St Helena Hospice in a mortality review group to review current practice and identify areas for improvement.

The number of deaths at Colchester General Hospital and Essex County Hospital (crude mortality) continues to fall year-on-year, even though the Trust is seeing more patients. There were 180 (-12%) fewer in-hospital deaths in 2013/14 compared to 2012/13 (1,363 from 1,543).

Mortality review meetings, which are attended by Executive Team members, are held weekly. These meetings are regularly open to all staff who wish to attend. There is also regular representation from primary care to allow wider learning throughout local health care providers.

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The Trust remains committed to take every possible step to prevent avoidable deaths.

Communication and engagement with staff A new survey has been introduced internally to gather sharper data on staff motivation, experience and engagement. This survey is now being administered for the second time (the first was in November 2013) with a response rate of more than 800 staff at all levels.

The results have been analysed along with those from the national NHS Staff Survey and a number of actions taken to begin to address the clear evidence of dissatisfaction in the workforce. While the communication of these actions has been understandably disrupted at times by changes at senior leadership levels, a campaign is well underway to increase staff recognition of the real actions being taken to address their concerns.

The most pressing concern of staff was behavioural. A series of workshops has now been delivered to challenge staff from executive to middle management levels about their leadership behaviours – with a specific focus on perceptions of managers bullying, discriminating and/or failing to listen effectively. The aim of the workshops was to facilitate a better understanding and dialogue between managers and staff – particularly when managing through difficult times. The sessions have been well received by non-executive directors, executives and also a wide range of clinical leaders (more than 300 attendees in all).

Concern has also been expressed about a clear sense of direction and clear leadership. Consequently, we are currently launching a values and behaviour model linked to the Trust’s strategic objectives and to existing leadership frameworks to ensure that staff have a clear understanding of what the Trust expects from them to support strategic goals, but also how it expects them to behave towards the public and patients, and internally towards one another. Executive, divisional and specialty level sessions will be delivered by senior leaders and organisational development/human resources expertise to facilitate discussion and ownership of the Trust culture – particularly in light of fresh concerns being raised about bullying behaviours.

In recognition that behavioural change requires both a shift in attitude and a shift in capability, the Trust is currently finalising design work on a suite of leadership development options which will be delivered in bite-size chunks to ensure accessibility. These options will include performance management and staff development, as well as finance and business planning.

Emergency Department (A&E) pressures The Trust is required to meet the national Emergency Department operational service standard of 95% of patients spending four hours or less from arrival to admission, transfer or discharge. Our performance against this for 2013/14 was 94.75%, compared with 96.09% the previous year. We failed to reach the 95% standard in five months last year. Our poorest performance was in December (89.77%) and our best in June (97.35%).

In common with the rest of the NHS, the Trust experiences spikes in demand all-year round, not predominantly in winter as was traditionally the case.

An Emergency Care Steering Group was established in January as part of the Trust’s Turnaround Programme, with an objective to put in place remedial actions to achieve the four- hour standard and clinical quality indicators. Its executive lead is the Chief Operating Officer.

A business case, based on demand and capacity planning for nursing in the Emergency Department, was developed and approved, resulting in 10 new adult and 10 new children’s nursing posts being recruited to for the Emergency Department. The Trust is working with Essex County Council to integrate two ward discharge teams (one from the Trust and another from the council) into a single service that will provide strong support to the wards with complex

6 discharges. A Nursing and Allied Health Professionals Forum, which meets every three months, has been set up between the Trust and Anglian Community Enterprise, which provide more than 40 NHS community health care services across north Essex, to improve working relationships.

Work is nearing completion on a 12-month £2.8m project to upgrade the Emergency Department (A&E) at Colchester General Hospital by expanding its capacity and improving patient flows. The department was built in the mid-1980s with an expected throughput of 35,000 attendances a year. Last year (2013/14), there were 77,757 attendances (compared with 76,338 and 73,504 in the previous two years). The work includes doubling the number of resuscitation bays from three to six, expanding the minors and majors areas, and creating a new children’s unit within the department.

Complaints A review of the Complaints Department took place in June/July 2013 and resulted in the appointment of a new Head of Department in October to look at the overall complaints process and where improvements could be made. Because of the huge media focus on the CQC cancer report published on 5 November, the Complaints Department that month received three times as many complaints as in the previous month. High numbers of complaints continued until February but have now stabilised and remain in line with numbers seen in previous years.

To address the high volume of complaints, the department changed the way it acknowledges incoming work. A basic acknowledgement letter/email is now sent to all enquirers within 48 hours of receipt, ensuring the department always knows how many complaints they have and gives the enquirer confidence that their issues are going to be addressed.

After providing a basic acknowledgement, the complaints team makes verbal contact with complainants. Complaints are agreed in discussion with the complainant and agreement is reached on the concerns they wish to take forward. Wherever possible the complaints team now tries to phrase these concerns into questions rather than statements. This allows for a more streamlined complaint investigation, with the investigators knowing exactly what they should be answering. Without any ambiguity, it reduces the number of complainants dissatisfied with the response they have received, therefore reducing workloads.

An advance in the way the Complaints Department checks all final complaint responses has ensured they are accurate and make sense to the complainant. Complaint replies have moved away from using technical terminology and try to use plain English throughout. The complaints team tries to put themselves in the position of the complainant. Previously the replies would be sent directly by those who had completed the investigation (within the Trust’s four divisions), and now the complaints team applies an extensive quality check. As a result of these checks the number of people reopening their complaints is reducing.

The biggest change that has helped monitoring and responding to complaints is alterations to the complaints reporting system used in the Trust. Daily reports are now available for the teams investigating complaints so they can see the complaint status and the item delaying the response. These are called “blocks to progress” and highlight problems that are being experienced, eg a clinician not able to provide a statement or an external response being required. This has allowed the investigating team to work on these blocks to try and remove them and improve the flow of complaint investigations.

Since these improvements were finalised and introduced at the beginning of the year, the Trust has seen the overall number of complaints fall significantly. In the last six months, the Trust received 548 new complaints, and provided 796 complaint replies (including to complaints made more than six months ago).Currently, 188 complaints are being responded to.

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Strong engagement by the divisions and the Complaints Department has greatly helped in reducing the number of complaints outstanding. Fortnightly meetings take place with leads in the divisions and the Complaints Department to analyse blocks in the progress of complaint answering, and to determine where continued improvements can be made. The key themes reported within complaints are concerns with clinical care and how the Trust deals with administrative issues and appointments.

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