Agenda and minutes

[To receive any apologies for absence].

Panel Member, Dana Tooby sent her apologies.

The Director of Public Health, John Denley and Consultant in Public Health, Ankush Mittal sent their apologies.

Dr Simon McBride (Clinical Director for Stroke Medicine) sent his apologies due to a long standing commitment.    

There were no declarations of interest.

[To approve the minutes of the previous meeting as a correct record].

The minutes of the meeting held on 16 January 2020 were confirmed as a correct record. 

[To consider any matters arising from the minutes].

The Scrutiny Officer advised that the Royal Wolverhampton NHS Trust were working on the failed discharged figures for the last three years and the Panel would be provided with them upon his receipt of the statistics from the Trust. 

[An open forum discussion with Health Partners about cancer screening, with a particular focus on breast, bowel and cervical.  The general theme will be – “What can we do to make things better”]. 

The Principal Public Health Specialist introduced the item on cancer screening.  She remarked that there was a priority in Public Health to halt the decline of cancer screening rates across the City.  She was hoping that all health partners would agree to taking steps to halt the decline and hopefully take measures to see an improvement in the uptake.  There were three main cancer screening programmes, breast cancer, bowel cancer and cervical cancer.  For each of the programmes there was a specific cohort of those that were eligible.  As an example she cited that breast cancer screening was for women that were eligible between the ages of 50 and 70.  They were invited to a screening appointment every three years. 

The Principal Public Health Specialist remarked that the screening rates for breast cancer in Wolverhampton were lower than the West Midlands and England average.  The current rate for breast cancer screening in Wolverhampton was at 56.8% compared to 71.5% for the England average. For bowel cancer screening, the uptake nationally was starting to increase, it was at approximately 71%.  In Wolverhampton the rate was at 69% and was not increasing, unlike in England and the West Midlands generally.  For cervical cancer screening the rates in Wolverhampton were lower than the England average, but there was a smaller performance gap than in breast cancer and bowel cancer screening.  She was aiming to try and fully understand why Wolverhampton was so consistently lower in cancer screening performance compared to the regional and country average. 

The Wolverhampton Healthwatch Manager remarked that Healthwatch were producing a report on cancer screening, but it was not yet ready to be circulated.  She was however willing to articulate the main headlines from the report.  They had engaged with 177 females over a period of time.  One of the key findings was that there was a fear of women not wanting to know whether they had cancer.  Another area that had arisen was regarding the flexibility of appointments, for instance not always having to attend Monday – Friday.  Some females had barriers due to their cultural needs and so they did not want to attend an appointment with a male physician.  She also noted that the letters were not currently tailored to a person’s ethnicity. 

The Wolverhampton Healthwatch Manager commented that some women had said that they would welcome some peer support to encourage them to attend.  Another headline from the report was that not all women knew the purpose of cervical screening.  The invitation letter did not explain everything in plain or simple language.  There were also some women who believed incorrectly that if they had received the HPV vaccine, then they did not require a cervical screening appointment.  She was happy to share the full report when completed with health partners. 

The Chief Executive of the Royal Wolverhampton NHS Trust remarked that he found it difficult to understand why the bowel cancer screening rate was falling behind the national and regional rates.  He felt that part  ...  view the full minutes text for item 5.

[The Panel will receive the results of the survey sent to all Patient Participant Groups].

The Director of Operations at the CCG (Clinical Commissioning Group) introduced the item on Patient Participation Groups (PPG).  He introduced the Primary Care Contracts Manager for the CCG and the GP Practice Manager for Probert Road Surgery.   

The Chairman of the Panel had provided the CCG with a list of questions to conduct an online survey with all the PPGs in the Wolverhampton area.  The responses had been collated into a presentation (the slides of which are attached to the signed minutes). 

The Primary Care Contract Manager remarked that all GP Practices were contractually obliged to have a PPG.  The CCG did monitor Practices to ensure that they had the appropriate group.  They visited Practices on a rolling programme as part of the contract review.  During the process they asked for agendas and minutes of meetings to ensure compliance.  Whilst the Primary Care Networks were quite new, they were already actively communicating with their patients. 

The Director of Operations at the CCG remarked that there were six Primary Care Networks across the City.  Four out of the six Primary Care Networks had responded to the survey and 19 out of the 40 GP Practices across the City.  Most GP Practices communicated with patients by phone, their website, email, letters and text messages.  The text messaging service and the screens in waiting rooms had been funded by the CCG.  11% of GP Practices had setup a virtual group, this was generally by email. 

The Director of Operations remarked that the Chairs of each of the PPGs would meet in their relevant Primary Care Network (PCN) Group.  75% of PCNs used email, letters and their website to communicate.  With reference to the survey question on how often PPGs met, close to 75% of PPGs met quarterly and all of the PCNs met quarterly.  Meetings were held at the Practice or within easily walking distance of the Practices.  The survey had determined that generally 6-10 people attended, sometimes less than 5 and occasionally there were groups which had more than 10 people attending meetings.  The survey results had shown that the Practices were not happy with the overall representation of people attending meetings.  In general PPG meetings did not attract young people.  It was felt that this was probably because most meetings were held in the day time, when people were working. 

The Director of Operations commented that one of the main issues raised at PPGs were appointments, which included availability and being able to contact the Practice on the telephone.  The CCG had been assisting GP Practices by helping them introduce different methods for patients to be able to book appointments, which included online bookings and electronic systems via the telephone.  They were also introducing video consultations to allow consultations to take place without the patient having to go into the GP Practice.  Other issues which were often raised included DNA’s (Did Not Attend), Patient Surveys, logistics and prescriptions.  Primary Care Network Groups often talked about general Practice related issues and the  ...  view the full minutes text for item 6.

[To receive a report on Midwifery Services at the Royal Wolverhampton NHS Trust]. 

The Matron (neonatal) from, The Royal Wolverhampton NHS Trust (RWT) introduced a report on Midwifery Services at the Trust.  The present birth to Midwife ratio was 1:27/28.  This was a positive ratio and met the recommendations of the birth rate and Midwifery acuity review of the Trust in 2017.  They did not have an issue in Wolverhampton recruiting Midwives, unlike some other areas in the country.  They had introduced the Midwifery Delivery Suite Coordinator, who had no caseload of their own during the shift, which allowed oversight of all birth activity in the area. 

The Matron remarked that they had took a decision to cap births after reviewing the birth rate in Wolverhampton.  Capping arrangements had been successful in maintaining birth rates within manageable levels over the last year with birth rates just under agreed commissioned activity.  Capping restrictions had since been lifted in October 2019.  Since the capping had been lifted, the bookings had started to rise but at a manageable level. 

The Matron commented that there were some significant changes happening in Maternity Services across England.  The Better Births Maternity Review and the NHS Long Term Plan (2019) had some ambitious objectives, which included a 50% reduction in still births, maternal mortality, neonatal mortality and serious brain injury by 2025.  The Trust were working hard to achieve the target across the region.  The key priorities to achieve the objectives were to ensure that the Saving Babies Live Care Bundle was implemented across every maternity unit in 2019. 

The Matron stated that there were 5 key elements to this Care Bundle which were outlined in the report.  The Trust reported quarterly progress to NHS England against the five key elements of the Care Bundle.  Recommendations from the national maternity review – Better Births were being implemented through the Local Maternity System (LMS).  The name was changing to Local Maternity and Neonatal System.  These systems brought together Local Authorities, CCGs, maternity providers and user groups.  They were aiming for women and their families to achieve seamless care across the maternity pathway, including between maternity and neonatal  service providers. 

The Matron remarked that one of the key recommendations from the Better Births Review was regarding continuity of care.  This required providing consistency in the midwife and clinical team that cared for her and her baby throughout pregnancy, labour and the postnatal period.  This was a key challenge for every maternity unit in the country.  In Wolverhampton they were anxious that continuity of care was not at the cost of safety.   They were therefore looking at the best model to support continuity of care but not at the expense of safety and quality.  They needed to achieve 51% of women receiving continuity of care by March 2021. 

The Matron commented that the Trust in 2019, fully achieved all of the 10 safety actions recommended within the Maternity Incentive Scheme.  The Trust therefore recovered the full element of their contribution related to the CNST (Criminal Negligence Scheme for Trusts) incentive fund and also  ...  view the full minutes text for item 7.

[To receive a presentation on stroke services at the RWT. The presentation slides are attached which will be explained in full by representatives from the Trust at the meeting]. 

The Group Manager of the Royal Wolverhampton NHS Trust introduced a report on Stroke Services at, The Royal Wolverhampton NHS Trust.   He gave a summary of the ongoing improvement work in Stroke Services.  The service had 39 beds, which were based at New Cross Hospital.  In April 2018 they had merged with Walsall’s Stroke Provision providing hyper acute and the acute aspects of stroke care.  The rehabilitation aspects were retained at Walsall on a well-established stroke pathway.  There were four hyper acute

beds on the unit.

The Group Manager commented that the biggest challenge with the merger was staffing.  They were now at the point where staffing levels were appropriate.  He commented that there was an extensive data failure in the latest quarter’s information which was included with the agenda pack.  The metrics were significantly attributable to a failure of the Trust to record information accurately.  They had improved the data quality since this time.  He described the statistics in great detail.  An A Unit meant the service was doing very well, an E Unit corresponded to poor.  Extensive training was taking place on the ward.  The gold standard was to give a stroke patient a bed within 2 hours and there was a target of 4 hours.

The Group Manager stated that they had been looking at how they could improve the SMR (Standard Mortality Ratio Figures) for stroke patients.  Several external reviews had taken place, both at their request and those that were mandated.  Extensive work had taken place to improve medical notes.  They currently had an external Medical Consultant working on the ward, reviewing all the medical notes for RIP patients.  They were challenging themselves to see if there was anything they could have improved in a patients care.  

The Group Manager commented that in the third quarter, the SSNAP (Sentinel Stroke National Audit Programme) requirement was for a patient to see a suitably trained stroke nurse within 24 hours, the Trust in the previous week achieved it within less than 15 minutes.  The requirement for a Doctor Review was within 14 hours and in the previous week the Trust had achieved it within 30 minutes.  They often would have a nurse and a Doctor waiting in the Emergency Department for the patient to arrive.  They had established a middle tier of Doctors using the Trust’s Clinical Fellow Scheme, which had been hugely successful.  They currently had four Clinical Senior Fellows who would be training over the next two years to become Consultants.

The Stroke Consultant commented that she had started working as a Stroke Consultant at the Trust in 2012.  There had been numerous changes to the service in this timeframe.  Consultant numbers had vastly improved and there had been an increase in beds.  They now provided an overnight Stroke Consultant and so a Consultant was available 24 hours a day. 

Members asked some technical questions about the performance statistics to which the Group Manager gave a full explanation. 

A Panel Member commented that his personal  ...  view the full minutes text for item 8.

The Principal Public Health Specialist introduced the urgent item on Coronavirus (Covid-19).  She stated that there were now a number of Coronavirus cases in the UK and there had been some reports the previous day of cases in the West Midlands.  Within Wolverhampton there was a key Multi-Agency Group consisting of the Local Authority, The Royal Wolverhampton NHS Trust, the CCG and Public Health England.  Regular communications were taking place.  Covid-19 was also a regular item on the Council’s, Strategic Executive Board (SEB) and there was a tactical co-ordination group that was below SEB. 

The Principal Public Health Specialist stated that, The Royal Wolverhampton NHS Trust had setup a Pod service where patients could be tested at New Cross Hospital away from the Emergency Department.  A Community swabbing service had also been setup that was testing people with suspected cases at home.  They were moving forward with plans for maintaining these services in the long-term.  They were looking at setting up drive through swabbing services to be available from the following week.  This would take some of the pressure off the Trust so they could prepare for increased Covid-19 cases.  Internally at the Council all of their guidance and communications were coming from Public Health England.  This was the same for the rest of the country.

The Principal Public Health Specialist remarked that the country was currently in the containment phase.  It was a new virus to humans and evolving.  It appeared to be similar to seasonal flu and so they could use their pandemic flu plans to help provide them with a baseline for preparedness.  They were in regular contact with NHS England and Public Health England.  The key message to residents at the present time was practicing good hygiene and the “Catch It, Bin It, Kill It” campaign. 

The Chief Executive of The Royal Wolverhampton NHS Trust stated that the messages were being carefully controlled by Public Health England, so they were somewhat limited as to what they could do and say.  He was sceptical about the effectiveness of the Pod system.  New Cross Hospital had 127 entrances and people would not find their way to the Pods, without walking through large sections of the hospital, irrespective of good signage.  He was procuring considerable building work in the Accident and Emergency Department, as they did not have enough places to isolate patients.  This was not unique to New Cross Hospital, no Accident and Emergency Department in the country had enough isolation areas. 

The Chief Executive of The Royal Wolverhampton NHS Trust remarked that he was now applying the principle of “Plan for the Worst and Hope for the Best.”  Over the next two to three weeks he would be planning for the worst.  The modelling that he had seen had led him to the conclusion that the situation was going to be awful.  A major concern was that there was not enough ventilator capacity to cope with the expected numbers.  This would mean applying what used to be  ...  view the full minutes text for item 9.

[To  receive an update report on the Mortality Agenda from The Royal Wolverhampton NHS Trust]. 

The Medical Director introduced a report on Mortality rates at, The Royal Wolverhampton NHS Trust.  It was a positive picture.  Over the course of the last 18 months, through the programme of work, the mortality statistics had declined steadily and were now in expected limits with the latest SHMI (Summary Hospital Level Mortality Indicator).  Extensive reviews of case records had taken place, they hadn’t found any evidence of avoidable deaths. 

The Medical Director explained that there had been a decline in the observed death rate, which they thought was related to the work in the community with nursing homes.  This was identifying patients where their end of life care could be managed at home rather than being transferred to hospital.  The patients that died in hospital in Wolverhampton was significantly higher than the national average.  But there had been an improvement over the last three years of observed deaths in hospital, which suggested more people were receiving their end of life care at home or their preferred place of death.

The Medical Director commented that they had extended the number of the new Medical Examiners to allow them to work more comprehensively.  They were aiming to have 90% of the deaths in hospital reviewed by the Medical Examiner.  

The Medical Director stated that they had completed a review of the quality of coding.  There had been some significant improvement over the last two years, which partly accounted for the better expected death rate.  They had been working with Price Waterhouse Cooper over the last 18 months who had reviewed the data collection systems, identified areas for change and provided intelligence with their predictive models to identify potential data quality issues on a case by case basis.  The independent Consultant had now left the organisation. 

The Medical Director commented that a significant piece of work was taking place on how they engaged with families.  It had been supported by Healthwatch. 

There were some questions to the Medical Director about the Medical Examiner Role and standards of care.  

The Scrutiny Officer commented that the digital monitoring of sepsis was being trialled in some hospitals, he asked the Medical Director to comment.  He responded that his thoughts were positive.  They currently used the traditional early warning scoring system to identify patients at risk of sepsis.  At the front door they had very good data, capturing most patients and they were treated in line with guidance.  There was a little fluctuation, but even at the busiest times they did very well.   He believed there was a particular problem with data capture inaccuracies when looking at the inpatient population, so he couldn’t comment on the performance for inpatients.  They were looking at some of the new digital technologies, which looked at tissue to try and indicate if the patient had sepsis.  They were going to trial them out soon and they had been given some samples.  A meeting was setup in the coming weeks with one of the companies.  He thought digital monitoring probably was  ...  view the full minutes text for item 10.

[To consider the Health Scrutiny Work Programme]. 

Resolved: That the Health Scrutiny Work Programme be agreed.