Agenda item

Betsi Cadwaladr University Health Board

Meeting of Special meeting, Social & Health Care Overview & Scrutiny Committee, Monday, 10th February, 2020 12.00 pm (Item 58.)

Representatives of Betsi Cadwaladr University Health Board have been invited to the meeting to:

(1) Give assurances over contractual arrangements with the Countess of Chester Hospital and service continuity;

(2) Respond to the outcome of the Notice of Motion considered by County Council on 28 January 2020 (attached); and

(3) Consider questions submitted by Members (attached).

Decision:

(a) That the answers given to the pre-prepared questions and the question raised at the meeting be noted;

(b) That written answers be provided on the late questions which were submitted to the Committee by Members;

(c) That assurances be given over the renewal of the contractual arrangements with the Countess of Chester Hospital to ensure service continuity and uninterrupted patient access (by the end of March);

(d) That an updated risk assessment on General Practitioner capacity and coverage across Flintshire be shared (by the end of April);

(e) That the Council and the Health Board continue to work closely together to plan future primary health care services based on population growth and community and house-building planning;

(f) That the Health Board involve the Council in scoping the planned review of Minor Injuries Unit service provision in Flintshire as a contributory solution to reducing demand on Accident and Emergency services (by end of April);

(g) That further information be shared on workforce recruitment, retention and training strategies with the Council supporting the proposal to develop a Medical School for North Wales;

(h) That the Health Board be encouraged to enlist the support of regional partners in negotiating with Welsh Government a sufficient and sustainable operating budget.

Minutes:

The Chair welcomed the representatives of the Betsi Cadwaladr University Health Board (BCUHB) to the meeting, and thanked them for their attendance.

The Chief Executive explained the reasons that representatives of BCUHB had been invited to the meeting, which were as follows:-

Give assurance over contractual arrangements with the Countess of Chester Hospital and service continuity;
Respond to the outcome of the Notice of Motion considered by County Council on 28 January 2020; and
Consider questions submitted by Members.

The Chair invited the representatives to provide assurance over contractual arrangements with the Countess Chester Hospital (CCH) and service continuity.

Mark Polin said that there had been a suggestion that issues around the contractual arrangements with the CCH had been the fault of the BCUHB and advised that this had not been the case. He did not anticipate the issue arising in the future and meetings to ensure that the Countess Chester Hospital were meeting their contractual arrangements were ongoing to ensure that the contracts would be signed soon.

In response to a question from the Chair around timescales, Sue Hill said that it was anticipated that the contract would be signed by the end of March. The Chief Executive suggested that feedback, once the contract had been signed, could be circulated to Members.

In response to a question from Councillor Carol Ellis around the term ‘activity not being delivered’, Mark Polin explained that the not all of the activity to be delivered by the CCH through the contractual agreement had been delivered and therefore further work was being carried out to better understand this prior to the new contract being signed. Simon Dean explained that this was usual process to ensure that the number of patients referred and treated by the CCH was set at the right level to ensure the appropriate resources were being made available.

In response to a question from the Chair, Sue Hill advised that there were no proposals to change the pathway for residents in Flintshire to access services at the CCH. Gill Harris said that she would like to see service increase, specifically around maternity services.

The Chair invited the representatives of the BCUHB to provide a response to the specific questions outlined within the Notice of Motion considered by Council on 28 January; 2020.

1. Is there sufficient capacity in Wrexham Maelor, Glan Clwyd and the Countess of Chester hospital?

Mark Polin invited Imran Devji to provide an update to Members on preventative measures and joint partnership working being undertaken at Wrexham Maelor hospital.

Imran Devji reported that a review of patients arriving in Accident and Emergency (A&E) who required urgent care had been undertaken in order to manage pathways and prioritise patients. During the review a number of factors were considered, including 1) the A&E profile hour by hour over the last 5 years; and 2) nursing shifts over a 24 hour 7 day a week basis. Following the review, key improvements had been made, specifically around clinical and acute services to increase the number of spaces in A&E to 57 and the introduction of physician consultation zoned areas. This new model had been welcomed by the clinical team who had been consulted during the review and he reported that the congestion rate had since reduced from 85/90% to 55/60%.

Mark Polin welcomed the improvement made and commented on the wide consultation which had taken place with nurses and clinicians. He also reported that he would be attending a meeting with Bangor University in order to progress the aspirations of having a North Wales medical school in order to meet future capacity needs.

In response to a question from Councillor Ellis, Imran Devji advised that the 57 additional spaces had been operational since 4^th November, 2019.

Councillor Ellis thanked Imran Devji and Mark Polin for their response and for recognising that there was currently insufficient capacity. She also welcomed the questions raised by Jack Sargeant AM with Welsh Government following the Council’s consideration of the Notice of Motion. She detailed a recent incident that had been reported to her from a resident within her ward and raised concerns over the length of time this lady had to wait without being offered any food or drink. She also commented on the Continuing Healthcare (CHC) and was concerned that BCUHB had one of the highest delays in patients receiving a care package over a 12 month period. Whilst she commended the work of the Council in providing support the patients waiting for a care package, she felt that this was the reason why patients were having to wait for a long time in A&E.

The Senior Manager - Integrated Services and Lead Adults reported that Flintshire County Council were currently ranked 7^th across Wales for their performance in providing care packages for patients leaving hospital.

Simon Dean apologised for the service experienced by the residents within Councillor Ellis’ ward and agreed to follow this up following the meeting. He commented on the importance of not working in isolation and the close links with social care colleagues and the need to continue to develop partnership based approaches to ensure the wellbeing of residents.

In response to a question from Councillor Gladys Healey around patients presenting at A&E with mental health issues, Imran Devji provided information on I CAN which was a new approach to improving the mental health and wellbeing of people across North Wales and the introduction of the new I CAN mental health support to shift the focus of care to prevention and early intervention, ensuring people received the right support in the right place at the right time.

2. Does Flintshire need a district General Hospital of its own?

Mark Polin commented on the need for Wrexham and Glan Clwyd Hospital to be performing to their optimum level which required the right staff and processes in place but said that appropriate primary and secondary services were needed in Flintshire to assist in reducing the number of people presenting at A&E. He provided information on the review of General Practitioners (GP’s) and community service resilience and reported that an updated risk assessment on General Practitioner capacity and coverage across Flintshire could be shared with Member by the end of April, 2020.

3. Why is the performance of A&E so poor in the Betsi Cadwaladr Health Board in comparison to the rest of Wales

Simon Dean explained that this was a wider system issue which affected England and Wales and was multi-functional. He commented on the ageing population and the need to find different models of care to meet a range of different requirements. He said that there was a great deal of work to do in partnership and had been pleased to hear the amount of joint working between BCUHB and the Council already being carried out.

4. What measurers can be put in place to urgently improve the performance of A&E by way of GP walk in centres, extended hours at minor injury units, improved access to GPs and improved community services?

Simon Dean reported that Welsh Government in 2019, announced a new set of standards for GP’s which should raise and improve the level of service for patients in Wales from their GP practices. Some of the new standards included 1) ensuring people received a prompt response to their contact with a GP practice via telephone; and 2) practices have the appropriate telephone systems in place to support the needs of people avoiding the need to call back multiple times. The new standards would be rolled out across Wales during 2020/21 and funding had been provided to support this.

Simon Dean also provided information on improvement carried out to improve access to Mold Minor Injuries Unit (MIU) which he said had been effective.

In response to a question from the Chair around the use of advanced technology, Gill Harries advised that ambitious use of digital technology was embedded in the Clinical Strategy in order to access care digitally for non urgent cases.

5. What is the level of investment that Welsh Government will be providing for patients in North Wales to stabilise and then improve performance?

Mark Polin advised that engagement with WG was being carried out to ascertain what financial assistance was required, what efficiencies could be made whilst continuing to deliver service improvement and what financial assistance could be provided to address tensions within the current system. This engagement had been positive.

The Chief Executive commented on the ability for regional partners to engage and offer support in negotiating with WG a sufficient and sustainable operating budget. Simon Dean welcomed this.

Councillor Paul Cunningham asked what the representatives thought was an acceptable waiting time for patients in A&E and spoke of his own experiences, some of which had been positive, and whilst the waiting times on a couple of occasions had been lengthy, he could not fault the service he had received. Gill Harris apologised for the delay experienced but was pleased to hear that Councillor Cunningham has received a good service. She advised that nobody should be waiting longer than they needed and that the focus was on managing patients on an individual basis to put appropriate plans in place.

Questions provided by Members of the Committee had been submitted prior to the meeting. The Chair invited the representatives of the BCUHB to respond to the questions.

What is the doctor/patient target ratio for Flintshire and where are they currently? How does this compare with both Wales and UK; and

If we are below target, what are they doing about it and why are they telling planners that their infrastructure can support new developments?

Rob Smith outlined how pressure on GPs was tracked. Through the new standards expected of GPs, WG were providing additional funding which would also improve access to services as it was not always necessary for people to see a GP and their needs could be met by speaking to or visiting a pharmacist/physiotherapist.

In response to the question around doctor/patient target ratio and increased house building, Rob Smith explained that there was no prescribed ratio. Simon Dean explained that BCUHB were consulted on future housing development as part of the planning process. The Chief Executive explained the process in the production of the Local Development Plan (LDP) and the need to collect a wide range of economic, social and environmental information to provide a factual base for the plan. The LDP needed to encourage development that was economically, socially and environmentally sustainable which covered all public services not only access to GP practices.

In response to a question from Councillor Ellis around the loss of a GP practice in Mold and the difficulties being faced by residents in Buckley accessing an appointment, Rob Smith explained that following the closure the service had been absorbed at a practice in Buckley and no request for additional support had been made. The set of standards expected by WG would improve access for making an appointment.

Councillor Carolyn Thomas commented on the need for improved public transport provision to enable residents in Mold to access the GP practice in Buckley.

In response to a question from Councillor Cunningham on the GP practice in Flint, Rob Smith advised that a primary care service would continue to be operated from the building and an advert for an independent practitioner had been published.

It has been said that Wrexham Maelor Hospital hires bariatric beds from private companies. Are you satisfied that equipment, which is on hire across the service is being returned as required and that BCUHB is not incurring excessive charges because of failure to return items?

Gill Harris explained that in some instances specific beds were required and these were hired from a private company. She provided an assurance that as soon as a bed was no longer needed, the company was informed and no further costs were incurred even if it took a few days for the bed to be collected.

The public are getting the impression that our hospitals are top heavy with management and that layers of management are themselves an obstacle for change. Do you believe that the time has now come for these layers of management to be cut so that resources can be redirected to the front line?

Simon Dean explained that good management was essential to enable clinical staff to carry out their role effectively.

Why doesn’t BCUHB make much more use out of Minor Injuries and X-Ray facilities which are available in local Community Hospitals which we fought to preserve for continued local use and to take the pressure off the General Hospitals like the Maelor?

Gill Harris and Rob Smith reported on a planned review of the MIU service provision which they recognised as a contributory solution to reducing demand on A&E services. The purpose of the review would be to maximise use of the MIU service and identify the provision required to do so.

Councillor Chris Bithell commented that the purpose of retaining the MIU service in Mold had originally been to take the pressure off general hospitals. Gill Harris agreed and advised of the actions being taken to appoint nurse practitioners and provide appropriate training in order for them to be appointed to the MIU service.

What steps are being taken to resolve overcrowding in Glan Clwyd and Wrexham hospitals? On Thursday last week when visiting the Hospital at Wrexham supplies and rubbish were being stored on corridors.

Imran Devji reported that a Corridor Management Plan was in place and that corridors were clean and clutter free to ensure patient safety. If equipment had to be stored in the corridor, firstly it was considered whether it was safe to do so.

Councillor Ellis commented on the difficulties for people with sight loss if equipment was stored in corridors.

How often are the wards deep cleaned?

Gill Harris reported that a great deal of work had been carried out to improve cleaning services at the general hospitals. A 24 hour cleaning service was available and this had been strengthened considerably. Occasionally patients need to be isolated to prevent the spread of infection and cleaning for these instances had improved also. The level of infections had considerably reduced and the clinical team and cleaning team have been supportive in achieving this.

What are the current levels of infectious diseases such as C diff at the two hospitals serving Flintshire?

Gill Harries reported that there had been a significant reduction in the levels of infectious diseases at the two hospitals which were now below the welsh average. Further information and figures could be provided to Members following the meeting.

What is the average waiting time of patients arriving in A&E needing and urgent bed?

The Committee agreed that a response to this question had been provided earlier in the meeting.

What is the policy on supplying food and drink whilst waiting in A&E for those who are elderly and alone?

Gill Harries advised that a Policy was in place within emergency departments for snacks and drinks to be offered to patients and this should be monitored every two hours. If this had not occurred then she said that she would follow this up following the meeting.

What is the procedure to get an Orthopaedic appointment and waiting time?

Gill Harries explained that orthopaedic appointments were made following a referral. Waiting times were between 8 and 26 weeks and it was recognised that this was too long, therefore support was being provided from WG to increase and improve orthopaedic services. A service review would enable BCUHB to develop pathways and in the short/medium terms engagement with external contractors may be necessary to meet the demand on the service.

In response to a comment from Councillor Thomas around the number of operations cancelled, Mark Polin advised that the delay in waiting times was being scrutinised by the BCUHB and was confident that with the support of WG the service would improve.

What is the latest position regarding the lack of GP’s and impact on all services.

The Committee agreed that a response to this question had been provided earlier in the meeting.

Why is there an ongoing nursing staff issue at Glan Clwyd Hospital?

Gill Harris reported that due to high demand in A&E, staff at Abergele Hospital had been re-located to Glan Clwyd Hospital to meet the demand. This was to enable gaps in rotas to be supported and to keep patients safe and the risk had to be managed on a day to day basis. Requirement issues for nursing and medical staff was recognised and focus was being put on recruitment and retention of staff and making sure the environment and models of care being delivered also contribute to the?ability to recruit staff.

Mark Polin reported that 28 out of the 29 patients who had had their operations cancelled and now undergone their planned operation. When questioned on the figures by Councillor Rosetta Dolphin, Mark Polin agreed to look into this following the meeting.

Councillor Healey thanked the representatives for their attendance and asked when they thought BCUHB would be removed from special measures. Simon Dean commented on the number of employees within the BCUHB accords North Wales and the commitment from everyone to see improvements being made. He also commented on the importance of joint working with regional partners across North Wales and the positive vision for improvements. If WG found that acceptable measures of progress was being made this would also assist in attracting high quality staff in the future.

In response to the clarification from the Chief Executive that BCUHB were entirely accountable for being in special measures and that partnership working by Local Authorities was not a contributing reason, Mark Polin agreed and explained that improvements were being implemented in a staged manner. He commented on the demonstrable progress being made around mental health services and said that everyone was incentivised to see improvements progress across services.

In response to a question from the Chair around debt levels, Sue Hill reported that debt levels had reduced over the last 12 months and that there were robust plans in place for them to continue to reduce.

Councillor Geoff Collett commented on the good work being carried out at Wrexham Maelor Hospital and the positive experience he had when visiting the hospital for an appointment. He commented on the earlier discussion around the MIU in Mold and said that he had been involved in raising funds towards the equipment had said he would like to see full use of the equipment being made.

In summing up the, the Chief Executive highlighted the following main issues arising from the discussion:-

That written answers to the late questions submitted to the Committee by Members be provided;
Assurances to be given over the renewal of the contractual arrangements with the Countess of Chester Hospital to ensure service continuity and uninterrupted patient access (by the end of March);
An updated risk assessment on General Practitioner capacity and coverage across Flintshire to be shared (by the end of April);
The Council and the Health Board continue to work closely together to plan future primary health care services based on population growth and community and house-building planning;
The Health Board involve the Council in scoping the planned review of Minor Injuries Unit service provision in Flintshire as a contributory solution to reducing demand on A&E services (by end of April);
Further information be shared on workforce recruitment, retention and training strategies with the Council supporting the proposal to develop a Medical School for North Wales; and
The Health Board be encouraged to enlist the support of regional partners in negotiating with Welsh Government a sufficient and sustainable operating budget.

Councillor Gladys Healey moved that the main issues arising from the discussion be supported as recommendations from the Committee. This was seconded by Councillor Carol Ellis.

The Chair thanked the representatives of BCUHB for their attendance and for responding to the questions from Members. The Chair also welcomed the joint working between the Council and BCUHB which she wished to see continue in the future.

RESOLVED: