Hands off Bedford Hospital has submitted an FOI request based on recent board minutes. Copy of that request below:
1. “Mrs Kobewka welcomed the excellent example of integrated care and queried how the service is funded. Ms Maryan-Instone informed the Board that the extended 7 day service is run within the same CCG commissioned budget and therefore different ways of working had been implemented, such as stopping community clinics. It was noted that this had not impacted upon patient experience”
What public consultation was there when stopping community clinics for COPD?
2. ” Notable achievements had been made by the service in improving patient experience – weekend working, respiratory review within 24 hours of admission, reduction in length of stay, reduction in bed days and a readmission rate of 4.2% compared to 12% nationally.”
 
Is this the reason that there is a Amber mortality indicator? Inadequate care at home? People finding it difficult to attend appointments when they don’t know where they’re going from one appointment to the next and at a greater distance?
3.” Mr Tisi informed the Board that as increasing numbers of patients are treated in the community the trust sees patients with higher acuity”
 
Are there overall figures? Is it possible that more people are dying because they reach a higher level of acuity before hospitalisation because they are now not receiving the ongoing care and attention that they need in the community? What are the figures?
4. What impact will there be on Bedford Hospital if the STP signs up to a shadow or full control total, how is this total fund allocated to each service?
5. “The Mortality Review Board would continue to proactively monitor mortality indices and commission reviews where required.

Mr Johns asked Mr Tisi if the trust is safe in light of the peak in mortality over and above the previous year. Mr Tisi informed the Board that the trust is safe but acknowledged that the peak in mortality is concerning coupled with the fact that staff were becoming very tired after months of working above and beyond.”
 
Has this been escalated to NHSI as per the minutes? What are you doing to ensure that the hospital gets the funding it needs, given that we are still in deficit and patients are not receiving optimum care? Have you been to the national press to alert them to the fact that people will die if something is not done soon. The public have the right to know.
Extracts from the Minutes of the Bedford Hospital Trust Board meeting
Patient Experience (COPD)
The Director of Nursing introduced Ms Fiona Maryan-Instone, Respiratory Specialist Nurse Service Manager to the Board to present on the Acute Respiratory Assessment Service (ARAS) and Early Supported Discharge (ESD).
Ms Maryan-Instone informed the Board that the integrated community COPD service had been commissioned in 2012 and it was noted that the service is available across the whole of Bedfordshire (Bedford Hospital and the Luton and Dunstable University Hospital Foundation Trust (L&D)). ARAS and ESD are a part of this service. The Board were informed that referrals to ARAS can be made by patients, paramedics, GPs, matrons, practice nurses and physiotherapists when a patient’s condition is heading towards an exacerbation to prevent attendance at A&E and a potential admission. The service aims to see and treat patients on the same day that the referral is received and patients can usually be discharged under early supported discharge to be cared for in their own homes. It was noted that 113 referrals had been received in the previous year. Ms Maryan-Instone informed the Board that the only issue currently facing the service was the lack of a permanent base on the hospital site due to the pressures the trust was currently facing which impacted upon patients not always knowing where they would be seen*. Notable achievements had been made by the service in improving patient experience – weekend working, respiratory review within 24 hours of admission, reduction in length of stay, reduction in bed days and a readmission rate of 4.2% compared to 12% nationally.
Mr Hone queried how the service is co-ordinated with the L&D. Ms Maryan-Instone informed the Board that there are two different teams led separately who liaise closely and meet monthly to ensure consistency. Mr Hone suggested that it would be useful to benchmark against the L&D service. Mrs Brigstock informed the Board that this piece of work was planned to be undertaken.
Mrs Kobewka welcomed the excellent example of integrated care and queried how the service is funded. Ms Maryan-Instone informed the Board that the extended 7 day service is run within the same CCG commissioned budget and therefore different ways of working had been implemented, such as stopping community clinics. It was noted that this had not impacted upon patient experience**.
Dr Gregson noted the amber COPD mortality indicator and queried if this had triggered a coding review. Mr Tisi informed the Board that as increasing numbers of patients are treated in the community the trust sees patients with higher acuity***. Dr Gregson highlighted the importance of the figures being supported by narrative so that whole picture can be seen. Mr Tisi agreed that triangulation of all available information is important.
Mr Johns queried what could be done to further improve the service. Ms Maryan-Instone felt that the service could be further improved with additional members of staff but recognised the financial constraints that the trust was operating under.
Mr Conroy queried if the service reaches in to care homes and residential homes. Ms Maryan-Instone recognised the importance of educating care home staff to confidently manage patient needs as it can become alarming for staff in care homes when residents become breathless. Dr Gregson highlighted the importance of linking the education to palliative care.
Mr Johns thanked Ms Maryan-Instone for presenting.
On the one hand:
*the only issue currently facing the service was the lack of a permanent base on the hospital site due to the pressures the trust was currently facing which impacted upon patients not always knowing where they would be seen
On the other:
**Ms Maryan-Instone informed the Board that the extended 7 day service is run within the same CCG commissioned budget and therefore different ways of working had been implemented, such as stopping community clinics. It was noted that this had not impacted upon patient experience.
What does this mean?
***Mr Tisi informed the Board that as increasing numbers of patients are treated in the community the trust sees patients with higher acuity.
Chronic obstructive pulmonary disease (COPD)

Bedford, Luton and Milton Keynes Sustainability and Transformation Plan (BLMK STP)

The Chief Executive informed the Board that the STP was working together to help all organisations close year end. Two main areas of focus for 2018/19 were:
1. A decision to be taken on whether to sign up to a shadow or full combined control total –
2. How to transform services and make effective use of transformation funding in support.
An extraordinary CEO and Director of Finance meeting had taken place to discuss projections and cost improvement plans to identify the level of unidentified savings and gaps in the system.
It was recognised that strong leadership in the community would be required to drive forwards transformation and manage risk.
Dr Gregson emphasised the importance of effective vertical integration to achieve the aims of the 5 year forward view.
Mrs Kobewka queried what could be done to strengthen leadership in the community to support delivery of transformation. Mr Conroy felt that the new community provider ELFT could provide strong leadership.
Mrs Kobewka felt that signing up to a shadow control total was the right thing to do to progress and queried what the associated risks were. Mr Reid agreed and informed the Board that the main risks were the CCGs financial position and the L&Ds control total. A financial model was being produced to demonstrate the gap. The model would be completed by the 23 March and a decision on whether to sign up to a shadow control total would be taken then. Mr Conroy informed the Board that the risk to the trust is more manageable in shadow form as if one partner fails to meet its control total the other organisations can still receive STF funding. Mrs Kobewka emphasised the importance of strong PMO management and the production of plans and funding mechanisms to provide incentives.
Lack of resources is putting patients at risk:
Performance and Assurance
3.1
Integrated Performance Report
The Chief Executive introduced the integrated performance report and informed the Board that the trust continued to be extremely busy. The Chief Operating Officer had given apologies to the meeting as she was running gold command on site. Mr Conroy informed the Board that performance metrics were worsening due to the sustained winter pressures. Elective operations had been cancelled and therefore the RTT position was not recovering as quickly as planned following the impact of the dermatology contract. A&E performance against the 4 hour target was the lowest it had ever been in January at 87.33% and remained at that level in February. Mr Conroy had been invited to meet with Paul Watson to discuss the trusts recovery plans. The Board were assured that patient safety remained the number one priority and there had been no 12 hour breaches. Mr Conroy informed the Board that the biggest issue in A&E was space linked to surge, on the Monday of that week 250 patients had attended A&E and the trust had started the day full. A critical internal incident had been called on the Sunday and the trust remained on critical internal incident.
Mr Hone queried if the issue was purely capacity related. Mr Conroy informed the Board that it was both flow and capacity related. The East of England Ambulance Service had recently instructed ambulance staff to convey patients to hospital and handover within 15 mins and then leave due to SIs in other parts of the region. This meant that in the evening when the Hospital Ambulance Liaison Officer is not on site nurses are required to cohort patients. Mr Conroy informed the Board that all hospitals in the area were under as much if not more pressure. Discussions were taking place daily with the CCG regarding delayed discharges at CEO level. Mr Johns informed the Board that he had visited A&E the previous day to thank staff on behalf of the Board.
Mrs Kobewka queried what the main drivers were behind the increased pressures. Mr Conroy informed the Board that the volume of patients attending was an issue, coupled with the lack of beds commissioned in the community to enable discharges. The trust had alerted the CCG following the previous winter that 50 additional beds would be required in the community but they were not provided for. Volume had increased and capacity had not. Patients were also older and sicker and the increase in frail 85+ patients impacts on length of stay.
Mr Gear expressed his concern for patient safety.
Mrs Brigstock informed the Board that she had spoken to the Deputy Chief Nurse for NHS England on Sunday to share learning regarding the measures the trust is taking to keep patients safe and was reassured that no additional actions were recommend over and above what the trust was already doing.
The Medical Director introduced the mortality section of the report and highlighted the key points;
 Mortality indices had peaked in January ‘18 and were higher than the previous January. Data was being interrogated regularly.
 As previously discussed the trust mortality rate was greater than the peer for COPD at 7.5% compared to 4.1%. This had triggered an amber alert and a review of coding of admission.
 A new outlier position had been flagged for congestive heart failure – 16% (20 deaths) compared to 10.5% in the peer group. A report had been commissioned through the Mortality Review Board.
 The Mortality Review Board would continue to proactively monitor mortality indices and commission reviews where required.
Mr Johns asked Mr Tisi if the trust is safe in light of the peak in mortality over and above the previous year. Mr Tisi informed the Board that the trust is safe but acknowledged that the peak in mortality is concerning coupled with the fact that staff were becoming very tired after months of working above and beyond.
Dr Gregson asked if the executive team were confident that the trust is providing the quality of service that the Board would aspire to and recognised a theme in the reporting of a tired and stretched workforce posing a risk of mistakes being made. Mrs Brigstock informed the Board that additional safety measures had been put in place, including external assurance reviews by the quality team from Bedfordshire CCG – the outcome of which had been generally positive. It was recognised however that the situation was far from ideal and could not be sustained long term – the trust was operating in mitigated safety. Harm was not being caused to patients but due to the immense pressure on staff optimum quality of care was at risk. Mr Johns requested that the executive team escalate the Boards concern to NHSI.
Workforce Management – nursing – note increased spend on Agency:
The Interim Director of Workforce and Organisational Development introduced the workforce section of the report and highlighted the key points;
 The sickness absence rate increased again in January from 3.91% to 4.09% but the trend was in line with previous years.
 Staff remained well engaged despite the immense pressures but the impact on staff resilience should pressures continue remained a concern.
 Staff survey results had dipped nationally but the trust results compared favourably to the national picture.
 Appraisal and mandatory training rates remained high in clinical areas despite the pressures.
 Agency expenditure had increased to provide additional cover for escalation areas and due to a decrease in stretched staff taking on additional bank shifts.

 

Trust Board Papers

FOI Request 24/04/2018

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