report from a clinical review of the barnet, enfield and haringey ... · the beh clinical strategy...

NHS England (London)

Report from a Clinical

Review of the Barnet,

Enfield and Haringey

Service Reconfiguration

September 2013


NHS England

London

Report from a Clinical Review of the Barnet, Enfield and Haringey Service Reconfiguration

Final Document Published: 5 September 2013

Prepared by:

Mark Spencer Angela Helleur Roger Durack

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Contents

1. Glossary of Terms and Abbreviations .............................................................................................. 4 2. Acknowledgements ......................................................................................................................... 5 3. Executive summary ......................................................................................................................... 5

3.1 Overarching Statement ................................................................................................................. 5

3.2 Background to the BEH Reconfiguration ....................................................................................... 5

3.3 External Reviews .......................................................................................................................... 7

3.3.1 February 2012 ........................................................................................................................ 8

3.3.2 August 2013 ........................................................................................................................... 9

3.4 Summary Findings/Conclusions and Recommendations .............................................................. 9

4. August 2013 Main Report .............................................................................................................. 13 4.1 Aims and Objectives ................................................................................................................... 13

4.2 Approach .................................................................................................................................... 13

4.3 Limitations of Method .................................................................................................................. 14

4.4 Detailed Findings/Conclusions and Recommendations ............................................................... 15

4.4.1 Site Visit – Chase Farm Hospital (09 May 2013) ................................................................... 15

4.4.2 Site Visit – North Middlesex University Hospital (13 June 2013) ........................................... 16

4.4.3 Site Visit – Barnet Hospital (11 July 2013) ............................................................................ 17

4.4.4 A&E Performance ................................................................................................................. 18

4.4.5 Urgent and Emergency Care ................................................................................................ 18

4.4.6 Bed Capacity ........................................................................................................................ 19

4.4.7 Workforce ............................................................................................................................. 19

4.4.8 Quality and Safety of Services .............................................................................................. 20

4.4.9 Primary Care ........................................................................................................................ 21

4.4.10 Internal Communications .................................................................................................... 21

4.4.11 Leadership and Engagement .............................................................................................. 21

4.4.12 Documentation Review ....................................................................................................... 22

5. Appendix 1 – Site Visit Schedule: Chase Farm Hospital ................................................................ 29 6. Appendix 2 – Site Visit Schedule: North Middlesex University NHS Trust ...................................... 30 7. Appendix 3 – Site Visit Schedule: Barnet Hospital ......................................................................... 31 8. Appendix 4 – Key Documents Reviewed ....................................................................................... 32


1. Glossary of Terms and Abbreviations

A&E Accident and Emergency AMU Acute Medical Unit BCF Barnet and Chase Farm Hospitals NHS Trust BEH Barnet, Enfield and Haringey BH Barnet Hospital CDU Clinical Decision Unit CCG Clinical Commissioning Group CCST Certificate of Completion of Specialist Training CFH Chase Farm Hospital CIP Cost Improvement Programme or Plan CNST Clinical Negligence Scheme for Trusts COEM College of Emergency Medicine CQC Care Quality Commission EAU Emergency Assessment Unit EM Emergency Medicine HDU High Dependency Unit HR Human Resources ICU/ITU Intensive Care Unit/Intensive Therapy Unit IRP Independent Review Panel KLOE Key Lines of Enquiry GP General Practitioner MAU Medical Assessment Unit MFE Medicine for the Elderly MLBU Midwifery Led Birth Unit MSP Managing Successful Programmes NICU Neonatal Intensive Care Unit NMUH North Middlesex University Hospital NHS Trust NHS NCL NHS North Central London PCT Cluster PAU Paediatric Assessment Unit PCT Primary Care Trust PCU Progressive Care Unit (same as a high dependency unit) PFI Private Finance Initiative PMBOK Programme Management Book of Knowledge PMO Programme Management Office POSCU Paediatric Oncology Shared Care Unit PPH Post Partum Haemorrhage RCOG Royal College of Obstetrics and Gynaecology RCM Royal College of Midwives RCPCH Royal College of Paediatrics and Child Health SCBU Special Care Baby Unit SHO Senior House Officer SoS Secretary of State SPR Specialist Registrar SI Serious Incident SRO Senior Responsible Officer UCC Urgent Care Centre WTE Whole time equivalent


2. Acknowledgements

The review team would like to thank all those who kindly contributed information allowing this report to be produced.

3. Executive summary

3.1 Overarching Statement

The Secretary of State’s (SoS), Independent Review Panel (IRP) findings in 2008 and a previous clinical review which took place in early 2012 support the case for change and the need to implement the proposed changes to improve patient care as set out in the BEH Clinical Strategy. This review has confirmed that it is necessary to make the proposed changes prior to the forthcoming winter.

In line with the BEH Clinical Assurance Terms of Reference (ToR) document, the external clinical assurance process was designed to provide assurance to commissioners, both Clinical Commissioning Groups (CCGs) and NHS England, regarding readiness to safely implement the changes. Specifically, final ‘ready/not ready’ decision making rests with the BEH CCG boards and provider boards will need to assure themselves, regarding their own readiness to implement the changes.

The assurance process was not designed to determine whether the service changes set out in the BEH clinical strategy should be implemented (this decision has already been taken) but was designed to ensure that changes are managed safely and that the final timeline for implementing changes minimises clinical risk.

It is acknowledged that a lot of effort, work and commitment have been made by all trusts, CCGs and the BEH central Programme Management Office (PMO) to reach the position that the programme is at currently. Great effort has been made to date with regard to managing and mitigating the potential risks involved in such a major reconfiguration, however, it was the role of the external review team to look for further risks and to scrutinise those already identified, to help the trusts and CCGs prepare even more robustly, to ensure that the provision of care remains safe and of high quality.

As an outcome of this review, the review team have, therefore, highlighted those areas that will need clinical and managerial attention to ensure that quality is maintained and improved throughout this service change. The review has confirmed that not only are the changes necessary, but that not proceeding with the changes will increase patient risk and jeopardise safety.

3.2 Background to the BEH Reconfiguration

The London Boroughs of Barnet, Enfield and Haringey (BEH) are located in the north of Greater London and have a combined population of around 870,000. The populations of all three boroughs are expected to increase over the next ten years. It is also anticipated that they will become proportionately older, with the biggest change expected in the number of people aged 45-64 years, who are at risk of long-term conditions such as diabetes, stroke and heart disease. The three boroughs are also extremely diverse; each one has large black and minority ethnic populations, and areas of moderate and high deprivation. Three acute hospitals, involved in the proposal, provide care for the populations of BEH; these being Barnet Hospital (BH), Chase Farm Hospital (CFH) and North Middlesex University Hospital (NMUH). BH is located in Barnet; CFH is located in Enfield and NMUH is also located in Enfield, although it also serves patients from Haringey and provides services to South Hertfordshire, resulting in BEH having a catchment population of approximately 950,000. Additionally, the Whittington Hospital provides care for the population of West Haringey and the Royal Free London Foundation Trust provides care for the population of South Barnet


NHS England provider activity return statistics1 for Q4 2012/13 show that the trusts provide the following activity:

Admissions GP Referrals 1st

Attendances Seen

Barnet & Chase Farm 8,670 32,076 30,104

North Middlesex 2,928 9,472 14,560

The BEH Clinical Strategy proposes changes to women and children’s services, urgent and emergency care and planned (elective) care across the three hospital sites. The plans were ratified in 2007 after extensive public consultation, an Equality Impact Assessment and an expert review by Professor Sir George Alberti2, as well as a review by the IRP, following a request by the local Joint Scrutiny Committee. Both the Alberti Review and the IRP Review concluded that health care services in BEH need to change.

In July 2009, the decision was taken to implement the programme in phases, with changes to women’s and children’s services to be completed by 2011. This included the provision of obstetric, neonatal and inpatient paediatric services at BH and NMUH, as well as the creation of a stand-alone midwife-led birthing unit (MLBU) and a Paediatric Assessment Unit (PAU) at CFH. The second phase of the programme included centralising emergency department services at BH and NMUH with a day-time Urgent Care Centre (UCC) and elective surgery to be provided at CFH by 2013.

In May 2010, the then Secretary of State for Health, Andrew Lansley, placed a national moratorium on future and on-going hospital reconfiguration proposals, including the BEH Clinical Strategy. In a speech delivered at CFH on 22 May 2010, he outlined new criteria (four specific tests) that service change proposals were expected to meet. A number of further reviews and consultations were then held which satisfied the requirements of the ‘four tests’. The trusts were given the authority to proceed in September 2011.

3The BEH Clinical Strategy identified the need to deliver better healthcare for the people of Barnet, Enfield and Haringey. The changes resulting from the proposed implementation of the strategy will see widespread improvements in local health services, including:

Improvements to primary care,

Expansion and redevelopment of emergency services at BH and NMUH,

Expansion and redevelopment of maternity and neonatal services at BH and NMUH, including the development/expansion of MLBUs at both, and

Development of urgent care services at CFH, including assessment centres for children and older people.

The case for these changes has strengthened over time, with the need to:

Ensure local services meet the adult London-wide quality standards,

Ensure the right staff are available to provide healthcare services, including providing the right level of consultant cover to meet quality standards,

Reduce the risks associated with the duplication of services,

1 http://www.england.nhs.uk/statistics/statistical-work-areas/hospital-activity/quarterly-hospital-activity/qar-data/

2 National Clinical Director for Emergency Access, 2002-2009

3 Taken from the Barnet and Chase Farm Hospitals NHS Trust website http://www.bcf.nhs.uk/about_us/beh-

strategy/index SAY WHEN ACCESSED

http://www.england.nhs.uk/statistics/statistical-work-areas/hospital-activity/quarterly-hospital-activity/qar-data/

http://www.bcf.nhs.uk/about_us/beh-strategy/index

http://www.bcf.nhs.uk/about_us/beh-strategy/index


Invest in local hospital facilities, bringing them up to modern standards,

Deliver a sustainable future for the local NHS, and

Expansion of planned surgery at CFH.

The BEH Clinical Strategy Programme is working towards implementation in November 2013. A final decision about the timing of the implementation will be taken by local Clinical Commissioning Groups (CCGs) in September 2013.

3.3 External Reviews

The BEH external clinical assurance process was designed to provide assurance to commissioners (both CCGs and NHS England) regarding the readiness to safely implement the changes. The process has 3 main components:

Final ‘ready/not-ready’ decision making by the Barnet, Enfield and Haringey CCG Boards,

NHS England (London) to provide assurance to NHS England / DH regarding readiness to implement changes, and

Healthcare provider boards to assure themselves regarding their own readiness to implement changes.

The assurance process was designed to ensure that changes were managed safely and that the final timeline for implementing changes minimised clinical risk.

The review team took a balanced approach between documentation appraisal and engagement with staff, assessing each of the four clinical work streams:’ preparedness for implementation; considering operational risks within existing services / current configuration to enable judgements to be made regarding the relative risks and benefits of proceeding in line with the current proposed timeline. The process sought to add value and strengthen preparations and help to mitigate risk.

The approach to the review has four stages:

1. Assessment and review 2. Feedback and response 3. Assurance and decision making 4. Post-implementation

Following the external clinical review, the draft report will be made available to the Regional Operations Director, NHS England (London) as part of the wider assurance process in place to ensure there is alignment between all 3 of clinical, financial and operational assurance reviews.

This report and the wider review by the provider trusts and NHS England will then inform the BEH CCG governing bodies as they make the ‘ready/not ready’ decision for implementing changes to services.

The timeline of assurance activities is as follows:

Date Activities

9 May Chase Farm Hospital site visit External review team attendance at Clinical Cabinet

13 June North Middlesex Hospital site visit External review team attendance at Clinical Cabinet

11 July Barnet Hospital site visit and walkabout External review team attendance at Clinical Cabinet

August External NHS England review team carry out assessment and produce feedback report to provider trusts

Throughout August Provider trusts respond to NHS England feedback report and consider their own


Date Activities

response

w/c 9 September Trust Boards make their decision

w/c 16 September NHS England produce a wider clinical, financial and operational final summary report, for CCGs

w/c 23 September CCG meeting in common – make final ‘ready/not-ready’ decision

3.3.1 February 2012

In February 2012, a first external review of the BEH configuration was commissioned by Caroline Taylor, Chief Executive, North Central London PCT Cluster and Senior Responsible Officer (SRO) for the BEH Clinical Strategy. The Review Team consisted of Robert McFarland, Vascular Surgeon and Independent Clinical Reviewer, Angela Helleur, Deputy Director, Medical Directorate, NHS London and Sue Dutch, Programme Manager, Quality and Safety Assurance, Medical Directorate, NHS London.

The scope of the review was to:

Assess the clinical risks of sustaining services in their current locations, taking account of; o Mitigation requirements, including additional staffing and physical capacity, o Impact of accreditation and training requirements,

Assess the clinical risks associated with transferring emergency services and women’s and children’s services at different times, including consideration for whether the preferred option was to (i) sustain services for longer in order to move them at the same time rather than (ii) move one service sooner,

Consider the clinical case for accelerating implementation of the strategy, and

Consider staffing requirements required for each workforce group to implement the changes safely.

The review team undertook a desktop document appraisal relating to the strategy and visited all three hospital sites to meet with members of each trust’s executive team and clinical and managerial leads. The review team was able to observe the current provision of children’s and young people’s services; maternity services; accident and emergency services (A&E); acute medicine; intensive care, anaesthetics and surgical services, explore issues and risks in their delivery and sustainability and discuss the changes proposed and associated benefits.

Three scenarios were applied as a framework to assess sustainability of services pending full implementation of the proposed changes; all were consistent with the overall reconfiguration set out in the clinical strategy. Consideration was given to the risks in each service in relation to each of the 3 scenarios.

The recommendation was that there was a very strong case for fully implementing the strategy as soon as possible, however, this was not without risks.

At the time, the review highlighted 3 particular risks where mitigating action would be required to safely sustain services, pending full implementation of the strategic changes. These were:

Paediatric on call consultant cover arrangements at BCF, which crossed the two sites, did not meet national guidance, particularly for neonatal units,

There was no dedicated consultant labour ward presence at BCF, therefore, did not meet national guidance or CNST level 1 standards, and

There were high levels of temporary staffing across BCF’s intensive care units (50-70% bank and agency nurse cover was reported on some shifts).


3.3.2 August 2013

In the first quarter of 2013 a second external review (the subject of this report) was commissioned by the BEH Programme Board for the purposes of providing expert, clinical and non-clinical comment to the BEH reconfiguration implementation team leading up to full implementation, so that the implementation team could provide assurance for the quality and safety of clinical services provided. In line with the BEH Clinical Assurance Terms of Reference (ToR) document, this review involved an assessment of already documented risks and the identification of new risks and the offering up of recommendations to assist the implementation team to assure quality and safety of services provided.

Approach to Review

Following a similar approach to the first review in February 2012, the review team undertook a desktop appraisal of key documents relating to the strategy and re-visited all three hospital sites to meet with members of each trust’s executive team, clinical and managerial leads. The review team was also able to observe the current provision of urgent and emergency care services at the BH site, to explore issues and risks in their delivery and sustainability.

As part of this review, the review team were also able to attend the monthly ‘BEH Clinical Cabinet’ meetings held at each site (as observers), during the months of May, June and July 2013.

Hospital Site Visits

The 3 main sites involved in the BEH reconfiguration are BH, CFH (Collectively known as ‘Barnet and Chase Farm Hospitals NHS Trusts’) and the NMUH.

The BEH central Programme Management Office (PMO) and trust teams arranged visits at each of the three main sites. At the NMUH and CFH sites, these visits followed a standard pattern of interviews with key executive, clinical and non-clinical staff in the morning, followed by attendance at the BEH Clinical Cabinet in the afternoon. For the BH site visit, the review team requested the additional opportunity to walk around affected clinical areas and to be able to interact with staff, to discuss and assess the changes underway. This opportunity was provided in the morning session.

Desktop Document Appraisal

In line with the BEH Clinical Assurance Terms of Reference (ToR) document, the review team were also asked to perform a desktop document appraisal. To complete this, the external team also requested a number of programme management related and non-programme management documentation from the BEH central PMO. A ‘desktop review’ was used to appraise these for both rigour per se as a document and for its content and contribution to an assessment of clinical risk. Details of documents reviewed can be found in Appendix 4.

3.4 Summary Findings/Conclusions and Recommendations

The BEH central PMO has facilitated good progress to date putting processes and structures in place to support the delivery of the BEH strategy to agreed timelines. This Clinical Review has however identified several areas, which are recommended for particular attention in order to provide sufficient assurance to the CCGs about readiness to proceed with implementation of the service changes as planned in November 2013.


The main areas of attention are as follows:

Accident and Emergency Services

Both NMUH and BCF have variable performance in the 95% four hour wait standard for emergency care4 and it is evident that the changes to the estate on both sites required to enable the service change to take place are impacting on performance. NMUH appears to have an understanding of what is required to improve performance to the required level.

Based on BCF Trust’ s weekly sitrep data submissions to Unify, at trust level, BCF has not achieved the 95% 4 hour wait standard in A&E since the week ending 31/03/2013 (Site level data is not reported to NHS England). Whilst implementation of the BEH Clinical Strategy will support improvement it is imperative that a whole health economy approach to supporting improvements is made. The review team is aware that BCF is in the process of implementing a number of improvement initiatives, which at the time of our visit showed limited evidence of impact, as they were at an early stage of implementation. It was recognised that the major building works have contributed to the challenges and the changes agreed will concentrate care at the major trust to improve performance once changes are implemented. A&E performance is a good measure of whole pathways in and through hospitals. Service changes in other reconfigurations have shown that continued attention is needed throughout implementation with a continuous focus on the quality and safety of care through this period. It has been noted that board oversight is in place, as part of the strategy to mitigate against this happening. It is the view of the review team that BCF will benefit from additional support to make the required improvements in a timely manner.

It is also recommended that plans to implement the London5 Adult Emergency Standards are fully described and that all aspects of accepted good practice with regard to urgent and emergency care be implemented, so that they can begin to be embedded before November. We are aware that this is underway.

Urgent and Emergency Care

Following a site visit to the Urgent and Emergency Care associated areas of BH, the safe management of acute admissions in low supervision units was an area that the team felt could be improved. Both trusts are now with the health and social care economy revising demand and capacity plans for acute pathways in order to be confident of providing capacity through the coming winter period.

Further development and consolidation of current mitigations are recommended to include:

Development of a further rehabilitation/low complexity unit at CFH,

Utilisation of additional space at Edgware Hospital, and

More urgent adaptation of integrated and ambulatory care schemes etc.

Bed Capacity

Bed activity modelling was carried out using 85, 90 and 95% occupancy rates. The decision to use the outcomes from the 90% occupancy rate was to provide greater flexibility in the system where current emergency bed occupancy is over 95%. This calculation resulted in the requirement for an additional 43 beds at BH. There has been further work since this initial modelling to ensure that schemes such as PACE, TREAT and RAID are implemented and also that improvements in discharge arrangements for patients are put in place.

4 Everyone Counts, NHS England 2013

5 London Quality Standards, NHS London, 2012


Other reconfigurations have used varied methodology and there is previous advice to consider 85%6 occupancy rate but as the trusts have been operating at >90% this capacity will give improved bed management. Confirmation of the delivered capacity will help CCG decision making.

Workforce

NMUH has a requirement for an additional 160+ nurses and whilst recruitment plans appear to be positive there is more detailed work to be concluded on developing contingency plans e.g. what the trust plan is should the numbers of recruited staff not meet the required level by a certain timescale. Both trusts need to ensure that all staff are familiarised and sufficiently trained and inducted to take on any new roles or changes to their current work. All partners are aware that having the required workforce in place is essential to deliver quality and safety.

It is recommended that the programme considers and ensures that contingency plans are sufficiently detailed to ensure than an adequately trained and available workforce is in place by the time of the planned changes.

Quality and Safety of Services

In major service change programmes, there is always a risk that the quality and safety of services will change before, during and following transition. It is important that the BEH Programme Board and trust boards consider the processes that will be required to effectively manage the risks to ensure there is a robust mechanism for systematically monitoring the quality and safety of services. The review team has seen and had the opportunity to comment on the current quality scorecard but feels that more work needs to be done to make the measures closer to ‘real time’, particularly during and after transition. Previous reconfigurations of services have shown that ‘quality of care’ needs close monitoring during periods of change when risks tend to be greater. Specifically with regard to colorectal surgery services, expert surgical opinion was sought to form a view on the quality and safety of the proposed changes. In summary it was considered that:

o Major colorectal cancer surgery should remain on the BH site, due to its interdependency with the emergency department and high dependency unit,

o Specialist colorectal surgeries should be centralised to an agreed provider within North Central London - this would have the effect of reducing the demand on beds, and

o An exploration of all opportunities to move appropriate inpatient stays to daycases, may offer up the release of bed capacity, for example, benchmark the current daycase rates for agreed procedures.

Primary Care

The BEH proposal, concerning the acute service reconfiguration is independent of primary care changes, however, the IRP recommendation and SoS statements referred to ‘continued implementation of improvements in primary care’.

There has been continued investment, and more is planned. We noted anxieties in the community and recommend that the changes already in place in primary care, that complement the changes in acute service provision, should be widely described and communicated.

6 Department of Health (UK). Shaping the future NHS: long term planning for hospitals and related services.

Consultation document on the findings of the national beds inquiry. London: Department of Health, 2000’


It is recommended that additional communication plans focus on the success of primary care changes and progress in achieving them and that communications are drawn up and shared with the appropriate stakeholder groups, to alleviate concerns.

Internal Communications

It is clear that there has been discussion with staff on all acute sites and that there has been good internal staff engagement, particularly regarding the impact of BEH on individual working arrangements. The formal staff consultation at BCF NHS Trust has now been completed.

The review team consider there to be an opportunity, however, to communicate more widely with clinicians and the community about the impact of the changes in clinical models and new developments. The new facilities and systems provide an opportunity to publicise the improvements being put in place.

Leadership and Engagement

It has been evidenced that the BEH central PMO and the programme managers at both sites are managing the programme with adherence to good programme management practice as defined by the core principles of both Programme Management Book of Knowledge (PMBOK) and Managing Successful Programmes (MSP) methodologies, which adds confidence to programme leadership

The clinicians who met with the review team appeared to be positively engaged with the process and eager for the transition to begin as they could see significant benefit for patients. The clinical leadership at BCF NHS Trust could benefit from further support to improve communication with teams involved in the emergency care pathways about the clinical delivery changes that are required, since it was expressed by some clinicians that they were not fully sighted on all of the anticipated changes

At NMUH, there also appeared to be good clinical engagement, evidenced by clinical lead involvement and support for the planned changes.


4. August 2013 Main Report

4.1 Aims and Objectives

The aims of the August 2013 review were aligned with the BEH Clinical Assurance Terms of Reference (ToR) document. This was interpreted so as to provide feedback specifically on the following:

All programme activities planned, carried out during or omitted from the transition phase leading up to the implementation, and

All programme activities planned for post-implementation

The specific objectives of the review were:

For the review team to carry out visits to each of the 3 sites to: o Informally interview a number of selected clinical, executive and managerial staff to

listen to their opinion on the reconfiguration, o Attend the relevant BEH Clinical Cabinets as observers, and o To walk around the relevant services affected at the BH site, to gauge opinion on the

reconfiguration

For the review team to carry out a desk-based documentation appraisal to form an opinion on both programme management activities and non-programme management activities around the reconfiguration with regard to clinical risk,

To provide regular and frequent informal feedback during the 3 month review period in a timely enough manner, so that the reconfiguration team could act on comment where appropriate, such that they could provide assurance to the BEH system on the level of clinical quality and safety provided, and

To provide a written report of the review findings to the reconfiguration teams at all 3 trusts in August 2013.

4.2 Approach

The August 2013 review took place over a period of 3 months and was structured around visits to each of the 3 hospital sites and a desk-top document appraisal. The review teams comprised:

SITE SITE VISIT DATE

FOCUS MORNING INTERVIEWS

MORNING WALKAROUND

AFTERNOON CLINICAL CABINET

CFH 09 May 2013 Maternity Dr. Mark Spencer n/a

Dr. Mark Spencer Roger Durack

NMUH 13 June 2013 Acute Medicine Dr. Mark Spencer Angela Helleur Dr. Susan LaBrooy

n/a Dr. Mark Spencer Angela Helleur Dr. Susan LaBrooy

BH 11 July 2013 Urgent and Emergency Care

Dr. Mark Spencer Angela Helleur Roger Durack Dr. Susan LaBrooy



Throughout the review period, the review team met with the BEH central PMO team to provide informal feedback, so that plans could be strengthened, or amended, if indicated without waiting until the full


review was completed. This was to assist the reconfiguration team to assure quality and safety during the transitional phase as well as to provide advice on maintaining quality post-implementation.

Following the final site visit in July 2013, comment and opinion from all three visits was gathered, discussed and agreed by the review team, and findings from a desk-based documentation appraisal were considered, before preparation of the draft report.

CFH and NMUH

For both of the site visits to CFH and NMUH, the BEH central PMO and the trusts arranged a number of 15 minute face to face interviews between the review team members present and a selection of clinical, non-clinical and executive members from the trust. These were informal in nature and provided trust staff with an opportunity to share their feelings and concerns with regard to (i) the progress of the reconfiguration to date to and (ii) service provision post-implementation. Notes were taken by the reviewers present, which were later group-reviewed to agree themes, to inform this report.

In the afternoons of both these site visits, the reviewers were invited to attend the relevant BEH Clinical Cabinet, in an observational capacity only. The Clinical Cabinet comprised the wider BEH clinical community, the BEH central PMO and the relevant trust executive with clinical representation. The Clinical Cabinet met to discuss progress against plan, to agree issues and planned resolutions, risks with planned mitigations, communication activities and other programme related matters. The Cabinet content was primarily driven by the BEH central PMO with the main thrust being the assurance of quality and safety during transition and assurance planning post-implementation. Additionally, clinical teams were invited to provide ‘in-depth’ presentations on how they planned to maintain quality with regard to the delivery of specific clinical services. Again, notes were taken, where appropriate, and these were later group-reviewed, prior to comment being published in this report.

Regarding governance arrangements, the Clinical Cabinet reported into the BEH Clinical Strategy programme board, which in turn reported to the Barnet, Enfield and Haringey CCGs.

BH

Similar to the CFH and NMUH site visits, the central BEH PMO and the trust arranged for a number of 15 minute face to face interviews to take place in the morning and for the review team to attend the Clinical Cabinet in the afternoon.

The review team had an opportunity to walk around the BH site, specifically urgent and emergency care related services, and to meet with staff from the relevant services so as to provide an opportunity for a range of staff to express their feelings with regard to the planned service changes and the planning leading up to the implementation of these changes.

4.3 Limitations of Method

Wherever possible the review team attempted to triangulate findings from the information gathered through the site visits, interviews with key staff and documentation provided.

The limitations of the review have included the impracticality of reviewing some specific information, , the relatively short time scale to complete the review and lack of access to expert clinical resource to accompany the team on some of the site visits. We are grateful for further advice from Mrs Celia Ingham-Clarke, National Clinical Director in reviewing the colo-rectal services.

It should also be noted, that in reviewing the emergency activity at BH, the work of the mental health teams was outside the scope of the review.


4.4 Detailed Findings/Conclusions and Recommendations

The Secretary of State’s (SoS), Independent Review Panel (IRP) findings in 2008 and the last clinical review in 2012 support the case for change and the need to implement the proposed changes to improve patient care as set out in the BEH Clinical Strategy. This review has confirmed that it is necessary to make the proposed changes prior to the forthcoming winter.

Overall the opinion is that the trusts are making good progress and have put in place actions to mitigate against the most obvious risks. The review team have, however, highlighted those areas that will need further clinical and managerial attention to ensure that quality is maintained and improved throughout this service change, to allow the CCGs to make a safe decision in the autumn. These areas are summarised later in this section.

The site visit over three months allowed the review team to see progression in preparing for the decision to progress with implementing the agreed changes.

4.4.1 Site Visit – Chase Farm Hospital (09 May 2013)

The following points were raised during interviews with clinical and non-clinical staff:

That a workforce tracker had been put in place to monitor recruitment to support the changes to services, which would deliver 98 hour labour ward consultant presence and a midwife to woman ratio of 1:30,

That there were concerns regarding the extent of the communication around the readiness of services in primary care, with one consultant stating “benchmarking and transparency needs to be bilateral”,

That there were concerns around bed capacity at each site and the modelling used, and

That further work needed to be undertaken re: London Ambulance Service specific protocols relating to the transfer of patients from the CFH Urgent Care Centre (UCC).

The Clinical Cabinet had good representation from BCF and NMUH as well as from the wider BEH community, with both provider and clinical commissioner attendance. At a high level the Clinical Cabinet focussed on 2 key elements; the first was a programme update and the second was a maternity-specific presentation termed a ‘deep dive’.

The BEH central PMO took the lead in driving the programme update content and covered how the external quality assurance process would fit into the current activity timeline. The reviewed capacity modelling was discussed. There were no concerns regarding maternity and paediatric capacity. The assumptions behind the bed modelling were discussed. More detailed work was to be conducted including plans for a whole system capacity planning workshop which was due to take place with the community and CCGs on 22 May to discuss the findings and develop an action plan across all 4 boroughs, together with a delayed transfer (discharge) audit planned to take place at BH in June and a further breakdown of modeled figures to be split by medical/paeds/maternity, which seemed a prudent action. The Quality and Safety Score Card, which contained metrics around performance, workforce, serious incidents (SIs) and patient experience, was presented. The model used was based on experience from other reconfiguration programmes. Whilst data collation was still in progress, it was considered a good beginning and that further work would look to its refinement. It was acknowledged that there was difficulty in getting information from the two trusts and that efforts linked to governance arrangements would help to improve this.


It was thought to be extremely useful for the purposes of quality assurance, to have the maternity clinical teams from both trusts jointly present their view of how quality and safety would be maintained before, during and after the implementation of changes. Although the teams presented current risks and strategies to mitigate these, the pathway for pregnant women with medical conditions was still unclear to some groups. The provision of fact sheets, an updated Directory of Services (DoS) for referring clinicians and during transition, the provision of guidance information for local GPs will be useful. The maternity data presented allowed for further questioning and discussion. It is suggested that the scorecard information should enable disaggregation of data by site and that the Clinical Cabinet bring together other sources of intelligence, such as patient experience. It was clear that recruitment was going to be the key issue for the maternity workstream. Hard to recruit staff such as ultrasonographers and neonatal nurses will need strong recruitment plans and contingency plans to be in place. There was a discussion regarding the changes to neonatal care and probing of the risks in relation to the need to transfer neonates at the time of transition. The trusts are mitigating this risk and working to reduce transfers to a minimum. A contingency plan to deal with this needs to be put in place between the relevant trusts and networks communicated with, to keep them sighted on this. The Clinical Cabinet also requested that workforce plans with detailed contingencies and co-dependencies be presented at the June Cabinet.

4.4.2 Site Visit – North Middlesex University Hospital (13 June 2013)

The morning was spent interviewing key individuals and through these interviews it became apparent that there were some concerns about the scale of the challenge in relation to nurse recruitment. There was a clear understanding of the numbers required but limited detail on how this would be achieved. The newly appointed Director of Nursing had only been in post for four days so there was an expectation that he would be key to leading this work within the trust.

The review team heard about the delay to the estates programme as a result of the discovery of asbestos in the ‘tower’. The Director of Estates appeared to be confident that the proposed new date for completion of works on the NMUH site would be realised. There was limited detail about contingency plans should there be any further delay.

Staff engagement around changes to working patterns appeared to have been communicated effectively, however, further communication around the changes to services was felt to be required for front line staff to fully understand these .e.g. an explanation of the whole plan and how individual clinical teams and processes fit into this. The Women’s Health team appeared to have worked hard on staff engagement and were confident that there was a clear understanding of the impact of the changes.

The team at NMUH were using the reconfiguration of services as an opportunity to work with partners across the health economy to improve patient flows.

The review team only reviewed the work of the Clinical Cabinet and were not involved in the Programme Board. The team felt that the identification of risks by the Clinical Cabinet could be strengthened and that the Cabinet should track the planned mitigating actions. The Clinical Cabinet focuses on clinical risks whereas the Programme Board focuses on the risks of the Programme as a whole. Two key areas that the Clinical Cabinet needs to continue to focus on include bed capacity and workforce recruitment as the programme progresses.

The Clinical Cabinet undertook a deep dive in paediatrics, for which there was medical paediatric representation from BCF. The plans for the transfer of all inpatient paediatrics at BCF were considered to be well thought through and no concerns were raised. However, the detail on the operational detail


for the Paediatric Assessment Unit (PAU) on the CF site required further review, particularly in relation to senior paediatric nurses and paediatric medical cover. It was noted that BCF had recognised this and had started to work through the changes required.

A review of the Quality and Safety Scorecard was undertaken with some discussion around the indicators and the use of the dashboard as an assurance tool.

There was discussion around the key risks for the programme and how some planned mitigations required continued work.

4.4.3 Site Visit – Barnet Hospital (11 July 2013)

From interviews, an overview of the staff consultation process was provided. It was not clear why there would still be a cohort of nurses/ midwives who could not be placed, particularly when NMUH had such a challenging recruitment issue. The staff consultation process at BCF appeared to have been robust and appreciated by the staff.

The obstetrics and gynaecology team were able to clearly articulate the changes and benefits for their services. The gynaecology team was particularly proud of the new facilities and delighted with the improvements to both the environment and potential to improve care for their patients.

The paediatric team was assured that the proposed arrangements for inpatient paediatrics, including neonatal services would bring positive benefits to children. The arrangements for emergency paediatric care on the BH site were not of concern, however, the operational arrangements for the Paediatric Assessment Unit (PAU) were still not finalised and there was some concern around the expectation of there being a paediatric medical presence at all times. This was felt to be impracticable, expensive and clinically of very limited benefit. The team had proposed that the PAU be staffed with senior paediatric nurses with a robust system for referral to BH when necessary.

Walking around the emergency department and Medical Assessment Unit (MAU), it was noticeable that A&E patient flow was suboptimal and that the building works alone would not lead to BCF meeting expected standards. A more joined-up approach would be required by all relevant clinical teams to improve this issue, particularly the relationship with acute medicine, to ensure that patients were not left on trolleys for longer than necessary. The review team were also of the opinion that the urgent care services needed to be improved to maximise efficiency. A GP led system was recently introduced for this service to ensure that patients, where appropriate, could be seen and treated more promptly with fewer patients transferred across to the A&E.

The Medical Director added his concerns to the capacity modelling that had been undertaken. He felt that the modelling that had been undertaken at 95% bed occupancy presented a risk to the quality and safety of services at BCF. The current bed occupancy of over 95% was likely to be contributing to the A&E performance. (It was noted that modelling had also been undertaken at 85% and 90% occupancy rates and that the base case is based on 90% occupancy). The review team was also informed that the team of colorectal surgeons had formally written to the trust to express their anxiety about the planned transfer of the complex colorectal surgery to the CFH site as there was no intensive or high dependency capacity on that site.

During the Clinical Cabinet there was a deep dive into urgent and emergency care services. It was acknowledged, that in some cases, the building works were having a small impact on the quality of service provided, but that there was also an increase in the number of emergency arrivals. Comment from the Clinical Cabinet, suggested that 1 Urgent Care Board (UCB) instead of 4, would result in better, more coordinated decision making across the local health economy


4.4.4 A&E Performance

The following graph shows BCF’s achievement of the 4 hour A&E standard. Achievement trend in 2013/14 is substantially lower than the previous 2 years.

In lieu of a root cause analysis of the poor achievement by BCF in 2013/14, it may be the case that this is compounded by the difficulties in working in temporary patterns during building works

Short term admissions also appear to be very high, which may be as a result of trying to manage the A&E challenge.

Achievement of the 4 hour A&E standard at NMUH is also challenged, but to a lesser degree than at BCF. It was noted that A&E re-admissions at the NMUH are also very high.

It is recommended that:

Greater visual management methods to monitor and expedite patient flow through A&E are implemented, thus allowing all staff to see at all times what patients are waiting for and by when,

A patient flow manager with the authority to mobilise activity when breaches are imminent may prove beneficial,

More timely analysis of short term admissions in a control chart format may help to indicate if processes are out of control or if the increase in admissions is expected and just needs to be better understood and managed,

Clear and efficient flow pathways for patients to AMU and medical wards are needed, and

A root cause analysis is conducted to elucidate causes of the issues.

4.4.5 Urgent and Emergency Care

Following a site visit to the Urgent and Emergency Care associated areas of BH, the safe management of acute admissions in low supervision units was an area the team felt could be improved. Both trusts are now, with the health and social care economy, revising demand and capacity plans for acute pathways in order to be confident of providing capacity through the coming winter period.


Further development and consolidation of current mitigations are recommended to include:

Development of a further rehabilitation/low complexity unit at CFH,

Utilisation of additional space at Edgware Hospital, and

More urgent adaptation of integrated and ambulatory care schemes etc.

4.4.6 Bed Capacity

Bed modelling across a large and complex healthcare economy is a difficult exercise and may resemble more of an ‘art’ rather than a science, due to the paucity of published, evidence based, models available. As a result, the actual activity that will move to each site or to other hospitals can, in our opinion, only be an estimate. We, therefore, advise that flexible capacity should be made available in case the shift estimates differ in reality from the modelling.

The modelling for build was based on a 90% bed occupancy rate, with additional modelling having been carried out at both 85 and 95% occupancy. Dr Foster reports “When occupancy rates rise above 85% it can start to affect the quality of care provided to patients and the orderly running of the hospital"7. Despite this, many trusts in London operate at occupancy rates higher than 90%.The modelling based on a 90% occupancy rate leaves an extra bed demand of about 43 beds in the new system. . There has been further work since this initial modelling to ensure that schemes such as PACE, TREAT and RAID are implemented and also that improvements in discharge arrangements for patients are put in place. The focus on capacity through the transition period will need continuous attention.

A previous BMJ article8 suggests that at 90% bed occupancy there is an approximate 5% probability of a bed crisis day – in this case, this is likely to be in the order of 18 days a year.

It is recommended that:

Bed modelling could be reviewed to ensure that all risks are mitigated against and contingencies in place to allow for flexible capacity in the system to meet demand, in case the shift estimates differ in reality from the modelling,

Contingency plans need to be in place, and

Contingency to address the potential of 18 bed crisis days per year should be put in place.

4.4.7 Workforce

To staff the new beds at the NMUH, the trusts have identified that an additional 160+ new nurses will be required. This figure would result in full establishment and no vacancy factor which currently runs at ~7%. Recruitment is now underway and, following interviews with key staff, the trust believe that they will gain a large majority of newly qualified nurses as they complete their training. A specialist recruitment agency is leading on this for them. There is a concern, however, that despite mitigations being in place to provide this large cohort of staff, details of contingencies (if the trusts do not attain this figure to safely run services) are not well developed and the training and risks associated with 160 ‘green’ (or recruited from overseas) staff have not been described well, particularly as the change will occur at the beginning of winter.

Any future demand and capacity modelling will need to take account of additional staff requirement.

7 Department of Health (UK). Shaping the future NHS: long term planning for hospitals and related services.

Consultation document on the findings of the national beds inquiry. London: Department of Health, 2000 8 ‘Dynamics of bed use in accommodating emergency admissions: stochastic simulation model. Adrian Bagust,

Michael Place, John W Posnett BMJ 1999;319:155–8’


The review team did note that at the August CF Clinical Cabinet, the NMUH Director of Nursing provided further detail regarding their plans to achieve the 160+ nursing compliment. He expressed a confident position with regard to achieving the recruitment plan and gave details of progress to date.

4.4.8 Quality and Safety of Services

A team of colorectal surgeons at BH had formally written to the trust to express their concern and anxiety about the planned transfer of the complex colorectal surgery to the CFH site as there was no intensive or high dependency capacity on that site.

In response to this, expert surgical opinion was sought to form a view on the quality and safety of the proposed changes. It was suggested that colorectal surgery advice (Celia Ingham-Clark, NHS England), facilitate a discussion with the senior medical staff at BH. Subsequently, it was their opinion that some of the colorectal surgery originally destined for the elective unit at CFH may not be safe if it moves to that site.

Based on the facilitated discussions between colorectal surgeons, the following comment and recommendations were made:

Major colorectal surgery (basically colorectal cancer surgery in which the large bowel is resected) should take place on an acute site such as BH rather than a ‘cold’ site. The primary risks of carrying out this type of surgery at a ‘cold site’ are around the occurrence of potential, early post-operative life-threatening complications that may require emergency re-operation and/or ITU care. It was acknowledged that this would add some pressure on surgical beds at the BH site, however, it has since been conveyed that this increased need in capacity has now been absorbed into the current cohort of surgical beds available, and

Major colorectal surgery should be at BH and should not be considered for a move to Royal Free London NHS Foundation Trust because of the very close association between major colorectal and major emergency surgery.

Additionally (regarding colorectal surgery),

It would be worthwhile ensuring that the shift from inpatient to daycase surgery has been optimised for all elective and emergency surgery (including hernias, anal fissure, anal fistula, haemorrhoids, peri-anal and pilo-nidal abscesses, simple distal limb fractures, Bartholin’s abscesses, ERPCs, emergency management of ureteric colic and urinary retention),

It would be worthwhile ensuring that the trust has fully implemented enhanced recovery through which it should be possible to achieve LOS of less than 5 days for THR and TKR, less than 10 days for anterior resection and AP resection, 1 day for almost all hysterectomies and may also impact on emergency cases. Needless to say enhanced recovery is about improving the care pathway to raise quality and remove un-necessary steps so patients go home fitter and sooner. Any attempt to simply force down LOS without implementing the whole pathway would be detrimental to patient care,

The requested expert clinical opinion also commented that a small proportion of very complex colorectal cases might be better treated elsewhere in a high volume centre and that there are other NCL sites that could be appropriate for this ultra-complex surgery, and

Finally, implementation of new guidance on managing surgical patients who develop a requirement for TPN for over 28 days may help – new guidance on this from the relevant CRG is that such patients should be moved to a tertiary centre. These patients may be very small in number but often occupy many bed-days.


4.4.9 Primary Care

The BEH Clinical Strategy proposal is about acute service reconfiguration and is independent of primary care changes. It is noted however, that the Independent Review Panel (IRP) recommendation and Secretary of State (SoS) statement refers to ‘continued implementation of improvements in primary care’.

Communication about the developments in primary care that complement the changes in acute service provision should be more adequately described and communicated. This would help to alleviate concerns.

It is recommended that a greater degree of communication of the challenges, developments and successes of GP and Out of Hours (OOH) services would help reduce anxiety and enhance confidence. To achieve this, there could be increased communication in content relating to the touch points between primary/secondary care, to provide assurance to both members of staff and external groups.

4.4.10 Internal Communications

It was clear, following discussion with staff at all sites and from attendance at the Clinical Cabinets, that the acute trusts have managed very good internal staff engagement, especially around Human Resource (HR) changes.

It is recommended, however, that:

There may be an opportunity to communicate both internally to staff and more widely the new developments in primary and secondary care, not only across both sectors, but also with local politicians and the public, and

To engage more widely with the groups mentioned above, a revision of the communications plan to include greater focus on these groups could help alleviate concerns in these areas.

4.4.11 Leadership and Engagement

It has been evidenced that the programme managers at both sites and the BEH central PMO are managing the programme with robust adherence to good programme management practice as defined by the core principles of both Programme Management Book of Knowledge (PMBOK) and Managing Successful Programmes (MSP) methodologies.

The clinical leadership at BCF could benefit from further support to enable greater engagement with the emergency care pathways and the clinical delivery changes that are required, since it was expressed by some clinicians that they were not fully sighted on all the anticipated changes

With the exclusion of obstetrics, gynaecology and paediatrics at BH, there seems to be concern among BCF consultants regarding service models, specifically around A&E, Acute Medical Unit (AMU), colorectal surgery and bed capacity. The programme manager and COO have put in place work to address it but there is still a lot to be done.

At NMUH, there appears to be good clinical engagement, evidenced by the clinical leads having ‘signed-up’, being involved and supporting the planned changes.

It is recommended that PM’s, COOs and Medical Directors need to work with specific staff groups to address the concerns of other medical groups


4.4.12 Documentation Review

In line with the BEH Clinical Assurance Terms of Reference (ToR) document, Key Lines of Enquiry (KLOE) were identified to support the development of the 4 clinical works streams. These KLOE were as follows:

Leadership and accountability

Demand, capacity and infrastructure

Workforce

Clinical pathways and protocols

Risks and issues, and

Communications

Where appropriate, documentation review feedback has been aligned to the above, as well as comment being provided on the rigour of the document itself, since this directly affects the reliability of the content.

Following a review of the documentation submitted a number of common themes needing attention emerged as follows. These aligned with similar themes following the site visits. They included:

Bed capacity

A&E patient flow / performance

Workforce

Communications

REF DOCUMENT TYPE DOCUMENT NAME COMMENT RECOMMENDATION

D1 Programme

Management Clinical assurance framework (final)

The clinical assurance framework rightly provided a selection of key clinical risks, controls, positive assurance, gaps in controls and action plans (activities) as an integral part of the risk management plan. It mainly presented the control type of working groups/committees with assurance of controls through external review by NHS England and CCGs.

A more balanced approach to control types to include policy, training, contracting etc. would have the effect of spreading risk. An extension, of the assurance framework to cover key programme level risks may prove beneficial especially to formulate action plans to address gaps in mitigation / contingency planning at the BEH system level



D2 Programme

Management

Risk register with contingency and mitigation

entries

The BEH central PMO had put a high quality and complete risk register in place which appeared to be maintained and updated regularly with comment. Split by both service line and at programme level, it covered the programme matrix style. At programme level, some risks described document-based mitigations, such as communications action plan, alternative recruitment plans from business units etc., some of which were still in development. From a service line perspective the creation of joint clinical work streams and regular deep dive feedback sessions at Clinical Cabinets seemed to focus on practical problem solving in a very positive way, as shown by the development of paediatric pathways in and out of primary care and quality indicators for paediatric care. Risk of not being able to deliver proposed mitigations or contingencies, e.g. foreign trained or newly qualified nurses, had generally not been included.

Risk register value could be augmented with the development of a system level dependency log, which would seem a vital requirement for the programme, where service lines are moving across sites. Any change in activity delivery against plan at one site will have either an outward or inward effect on activity delivery at another site, if there is a dependency. It was unclear where dependencies were being captured, monitored and managed at a higher BEH programme level.

D3 Other

Minutes and Actions from BEH Clinical Strategy

Programme Board 23 May 2013

Minutes were well structured and reflected attention well on the 4 clinical services, risks, commissioning reports, provider reports, communications and workforce. They clearly demonstrated that the programme had good visibility at board level with candid and honest reporting

None

D4 Other BEH Clinical Strategy Programme Summary

Report 18 June

The programme work stream update reports were of good quality and focussed in proportion on risks, issues, deliverables and dependencies. Work stream risk dashboards were frank and provided good

None



comment together with trend directionality. Overall, the impression was one of open reporting with the critical path display adding value to an audience that may not be familiar or comfortable with programme plans

D5 Other

BEH Clinical Strategy Review Stage One

Summary Report Enfield Council - 8th May 2013

The paper was commissioned by Enfield Council and questioned the ability to deliver developments in primary care.

The ’deep dive’ into primary care will helpfully demonstrate on-going development in the delivery of primary care services.

D6 Other

BEH Clinical Strategy Programme Activity

Transfer & Bed Model Summary

Although the model listed the assumptions upon which the calculations were made, the reason or underlying evidence for the assumptions was not clear. A bed occupancy rate of 90 or 95% does not follow some published recommendations that an occupancy rate of 85% be used when modelling for bed capacity9. Many other service redesigns have modelled re-providing historic occupancy. Modelling at 90% should allow improved patient flows and bed management.

Appendices with full, supporting calculation logic would help add legitimacy and confidence

D7 Other

Review of progress on meeting the Independent

Reconfiguration Panel (IRP) recommendations –

18 June 2013

This document was aimed at describing the evidence to support how the 12 recommendations in the IRP would be met. The report also provided a guide as to how meeting the evidence was progressing. Although at least one form of evidence was provided for each recommendation, more comprehensive evidence could have been proffered, e.g. For the establishment of appropriate implementation management arrangements, the provision of the

In parts, the submission of self evidence could have been further strengthened by a more comprehensive listing of sources.

9 Department of Health (UK). Shaping the future NHS: long term planning for hospitals and related services. Consultation document on the findings of the

national beds inquiry. London: Department of Health, 2000



programme governance structure is just one aspect which could augment this. An implementation team plan, roles and responsibilities chart would further support the establishment of appropriate implementation management arrangements.

D8 Other Chase Farm Vision

booklet

The vision booklet presented a comprehensive guide as to the service CFH would offer after implementation of the BEH reconfiguration changes. The inclusion of ‘patient scenarios’ further supported ease of understanding for the patient.

None

D9 Other BEH Recruitment Plan

Summary

The recruitment plan submitted was for NMUH only. There was some ambiguity over the numbers, e.g. there appeared to be no additional recruitment for midwives per se, despite an approx. increase of 1,000 births at that site. To compound this, recruitment was on-going as demonstrated by the offer of 10 posts. There was also inconsistency in the appropriation of RAG status, e.g. both under and over-recruitment received an amber status

Better consistency or at the very least an explanation of the how RAG statuses are appropriated could accompany the document. Also, the midwife inconsistency requires remedy. A collation of movement to include additional recruitment, loss and secondment would add value by presenting the overall picture – projected against actual in graphical format.

D10 Other BEH Clinical Strategy

Programme Work Stream Reports

Reports are split by work stream and included dependencies, thus providing a more rounded approach to risk management. Allocation of the overall RAG status was unclear, since this seemed to vary between work streams with an ad hoc allocation, which could give a less than accurate assessment.

Despite changes in primary care being separate to the BEH reconfiguration, inclusion of a primary care report would add richness to the overall system changes planned and provide reassurance to local councils


Programme Trust Reports

Board Assurance Framework Reports have a strong appetite for risk. The BCFH report covered primary care and the financial

A way of quantifying the financial return of changes at certain points in time to mitigate against costs/returns not being



sustainability of change. Contingency with regard to bed / activity management and workforce planning is in development. NMUH risks around estate reconfiguration (women’s and children’s centres) were covered, together with recruitment to nursing, midwifery and A&E – recruitment plan details are again being strengthened

met may be useful. Dependency management could be strengthened.


Programme CCG Reports

Clear transparency and description of risks around how UCCs would support the displaced demand from A&E.

None

D13 Programme

Management Benefits Realisation

Framework

The report was based on RAG style reporting, which may not be the most appropriate format for measuring process improvements. A quarterly report may not aid an immediate response to a deteriorating situation. The BEH ‘Benefits in a nutshell’ is a good example of how to tailor information for patient groups Inputs/outputs/outcomes value chain clearly and concisely linked, however, primary care benefits included here are not reproduced in other documentation

Consideration could be given to using control charts to show how specific service changes have had a direct effect on benefits. Monthly measures would provide a more timely view of quality.

D14 Other Clinical Assurance

Framework Terms of Reference

Clear description of the areas to be reviewed with the aim of providing assurance, the purpose of assurance and the staged approach, together with how key lines of enquiry will be used to support the review.

Although there is a slight bias towards providing assurance at the level of individual site, there would be value in providing an additional key line of enquiry where consideration is given to the BEH healthcare system as a whole

D15 Programme

Management Programme Delivery Plan

Standard cascading level milestone programme plans provided

Delays to delivery overlaid on plan or a tracked plan would be useful

D16 Other Website Programme Implementation Plan

The programme implementation plan provided a good overview of the changes occurring in the local community. Some of

May need a refresh at a point before November.



the information with regards to slipped timelines was out of date (e.g. Junior doctor rotation sign-off by Deanery). Much of the document’s value was in presenting milestone planning both by hospital site AND then by work-stream.

D17 Programme

Management Communications plan July

to Sept

Communications plan was strategic in style and thoroughly covered audience, content and timeliness. A delivery channel milestone map was provided. This specific plan was strategic and was not intended to function as a tracker.

A method of measuring effectiveness of communication goals would add assurance around the audience being reached: specifically with the general public. A communication tracker would add value.

D18 Other Clinical Quality and

Safety Scorecard

The Quality Scorecards are constantly evolving in response to user comment, however, their format can still be improved upon. Some BCF data i.e. patient experience is still required by site and the births: midwife ratio is not presented correctly.

Analytical review/advice on the scorecard could add value to the presentation and interpretation of the information. ‘How to read’ information bubbles could assist users, who do not frequently use data, to understand better the information therein.

D19 Other NMUH Trust Board

Assurance Framework Risk Heat Map July 2013

The ‘heat map’ presented a listing of BEH related risks that have an impact at corporate level. The map quantifies the impact of the risk in terms of the product of likelihood and severity and also provided an indication of direction, since the last report. The report did pick up the workforce risk with an indication that failure to recruit adequate staff would delay the transfer of services to the NMUH. Implementation slippage would impact the NMUH trust financial position and failure to improve primary care services could see higher than predicted patients treated at NMUH. The risks were not diminishing in impact, which may indicate uncertainty in the effectiveness

Log the risk that the mitigation actions to deliver the bed capacity needs of the new system may not be addressed in planned time scales and could then delay implementation of some parts of the programme.



of mitigation strategies

D20 Other BCF Trust Board

Assurance Framework June 2013

Adapted BAF template which listed the assurances, controls and gaps in mitigation against risks. Key BEH risks picked up were: workforce recruitment (again, no mitigations described in the event that the recruitment strategies should not deliver), decreasing staff engagement (mitigated by various communications strategies and working groups) and unexpected costs due to building works, (mitigation of establishing a programme board lacked detail)

Gaps in controls described as ‘Nil’ perhaps need revisiting. If there is a chance that the mitigations do not have the desired affect, then there will be a gap and a need for further contingency

D21 Other NMUH Trust Board

Assurance Framework June 2013

Commonly used BAF template. At a high level, delivery of the BEH strategy appeared frequently as a mitigating action to other risks (compliance with Adult Emergency Standards (AES), national guidance and best practice compliance etc.), when delivery of the BEH strategy itself had high risk associated with it. Risks of workforce recruitment, inadequate communications, and inadequate development of primary care services included. Additionally, financial contribution of BEH implementation to trust income is a high profile risk with good mitigations, however, there was again no contingency should current recruitment mitigations fail and transfer of services does not take place. BEH was seen as major support to the trust’s FT application.

Suggestion to add contingencies around failure to recruit required workforce, so that (together with providing sufficient bed capacity at BH), the implementation of the BEH strategy in line with current timelines, has greater assurance, especially if delivery of the BEH strategy is itself a mitigation to other corporate risks


5. Appendix 1 – Site Visit Schedule: Chase Farm Hospital

BEH Clinical Strategy - External Clinical Review team

Itinerary for 9 May 2013

Location: Strategy offices, Barnet and Chase Farm NHS Hospitals Trust Headquarters, Chase Farm Hospital, The Ridgeway, Enfield, EN2 8JL

Point of contact for the day:

Cathy Geddes, BCF Trust Programme Director, 07837 394157 [email protected]

External Review team members from NHS England:

Dr. Mark Spencer and Roger Durack

Agenda

11:00 – 11:20 - Raj Chana and Veva Attoh-Quarshie (workforce)

11:20 – 11:40 – Scott Johnson, Elizabeth Raiden and Adam Rodin (Women’s services)

11:40 – 12:00 – Jenny Galpin – Project Manager – Chase Farm site

12:00 – 12:45 – Lunch with Cathy Geddes

12:45 – 13:00 – Turan Huseyin and Rick Strang (Emergency Care)

13:00 – 13:15 – Stephanie Watt (Planned Care)

13:15 – 13:30 – Jean Aldous (Medicine)

13:30 – 13:45 – Simon Roth and Elizabeth Raidan (Paediatrics)

13:45 – 14:00 – Kevin Howell (Estates)

14:00 – 14:15 – Ian Mitchell (Medical Director) and Terina Riches (Director of Nursing)

14:15 – 14:30 – Alex Hickinbotham – Implementation Manager

14:30 – 17:00 – Clinical Cabinet – Maternity Deep Dive (papers to follow)

mailto:[email protected]


6. Appendix 2 – Site Visit Schedule: North Middlesex University NHS Trust


Itinerary for 13 June 2013

Location: Meeting room B, ground floor, North Middlesex University Hospital NHS Trust Headquarters, Sterling Way, N18 1QX

Point of contact for the day:

Richard Gourlay, NMUH Trust Programme Director, 07587 656626 [email protected]

External Review team members:

Mark Spencer, Angela Helleur, Susan LaBrooy

Agenda

10:00 – 10:45 – Richard Gourlay (Programme Director)

10:45 – 11:30 – Kevin Howell (Estates Director)

11:30 – 12:00 – Frances Evans (Associate Medical Director)

12:00 – 12:30 – LUNCH

12:30 – 13:15 – Maurice Cohen and Jonathan Gardner (Medicine)

13:15 – 14:00 – Emma Devereux (Women and Children)

14:00 – 14:30 – Rachel Patterson (People and Organisation Development)

14:30 – 17:00 – Clinical Cabinet – Paediatrics Deep Dive (papers to follow separately)



7. Appendix 3 – Site Visit Schedule: Barnet Hospital


Itinerary for 11 July 2013

Location: Palm Ward Board Room, Level 3, Barnet Hospital, Wellhouse Lane, Barnet, EN5 3DJ

Point of contact for the day: Cathy Geddes, BCF Trust Programme Director 07837 394157 [email protected] External Review team members: Mark Spencer, Angela Helleur, Susan LaBrooy, Roger Durack Agenda

10.00 - 10.30 Walk around with Cathy Geddes/Turan Huseyin

10.30 - 11.00 Emergency Services - Turan Huseyin - Clinical Director

11.00 - 11.30 Women's Services - Elizabeth Raidan - General Manager Elizabeth Morakinyo - O&G Consultant Sue Hall - Gynae Matron 11.30 - 12.00 Paediatric Services - Elizabeth Raidan - General Manager Tim Wickham - Paediatric Consultant

12.00 – 13:00 Lunch with Cathy Geddes

13.30 - 14.00 Fiona Smith - Chief Operating Officer

14.00 - 14.30 Ian Mitchell - Medical Director

14:30 – 17:00 Clinical Cabinet (Deep dive presentation into Emergency, Acute and Urgent Care)



8. Appendix 4 – Key Documents Reviewed

A number of programme management and non-programme management related documents were requested from and provided by the BEH central PMO for appraisal.

In a lot of cases, specific documents did not exist per se, however, similar content was often provided in alternative documentation.

Main documents reviewed were as follows:

DOCUMENT REVIEWED

Risk register with contingency and mitigation entries

Quality assurance framework (final) Minutes and Actions from BEH Clinical Strategy Programme Board 23 May 2013

BEH Clinical Strategy Programme Summary Report

BEH Clinical Strategy Review Stage One Summary Report Enfield Council - 8th May 2013

BEH Clinical Strategy Programme Activity Transfer & Bed Model Summary Review of progress on meeting the Independent Reconfiguration Panel (IRP) recommendations – 18 June 2013

Chase Farm Vision booklet

BEH Recruitment Plan Summary

BEH Clinical Strategy Programme Work Stream Reports

BEH Clinical Strategy Programme Trust Reports

BEH Clinical Strategy Programme CCG Reports

Benefits Realisation Framework

Clinical Assurance Framework

Programme Delivery Plan

Website Programme Implementation Plan

Corporate risk registers (Board Assurance Frameworks)

BEH Clinical Review Final Report, February 2012, NHS London BEH Capacity Modeling HB Amends 030713 (Provided 21 August 2013) BEH Capacity Plan v0.4 (provided 21 August 2013) Adult Non-elective Bed Forecasts at 85% (provided 22 August 2013)