Brighton and Hove doctors share safety concerns

The doctors leading the NHS reforms in Brighton and Hove met in public shortly before they formally took charge last week.

The reforms are meant to give clinicians more say over services and they are taking their new responsibilities seriously.

Among the key issues discussed by the Brighton and Hove Clinical Commissioning Group (CCG) were finances and patient safety.

The CCG, chaired by Brighton GP Dr Xavier Nalletamby, is being expected to spend less on administration and bureaucracy than its predecessor, the primary care trust (PCT).

But it is also under pressure to find ways to improve the quality and safety of treatment given to patients throughout the area.

Similar pressures on hospital bosses were behind a demo held outside the Royal Sussex County Hospital in Brighton at the weekend.

At the public CCG board meeting, held at Hove Town Hall, a quality and safety report spelt out other key areas of concern.

It highlighted, for example, incidents of the hospital superbug MRSA, delays in treating cancer patients and the case of a swab left inside a mother who had just given birth.

Those involved Brighton and Sussex University Hospitals NHS Trust which runs the Royal Sussex.

The pressure on the Accident and Emergency (A&E) Department at the Royal Sussex is on their radar.

The numbers turning up at A&E have soared and at times it has taken patients longer to be seen than the target of four hours.

The CCG has also stopped referring new neurosurgery patients to the trust. The suspension is expected to last between three and six months with new patients being sent to London or Southampton for treatment.

The trust running the Royal Sussex “is considered to be a challenged organisation”, according to the CCG.

It said the same about Sussex Community NHS Trust (SCT). The report to the CCG board said: “Performance and quality is scrutinised monthly.

“Ten key quality and safety indicators have been developed to be reported upon monthly but this (information) has consistently failed to be provided by SCT.

“Reports are minimal, offering no narrative on performance and risks.”

The CCG flagged up concerns about whether all patients’ nutritional needs were being properly recorded.

And it is not always clear what level of patient care should be handled by non-clinical staff such as home care helpers who are employed by Brighton and Hove City Council.

The report to the CCG board said: “This is a potential patient safety risk.”

The matter is being tackled urgently at a senior level.

The report also identified areas of concern for mental health patients although it said that the main local NHS provider, the Sussex Partnership NHS Foundation Trust, was “considered to be in steady state”.

The trust is focusing on improving patient experience. Patient surveys by the Care Quality Commission (CQC), the official watchdog, show an improvement in this area but the most recent still ranks “worse than other trusts” for involving patients in relation to their medications.

The CCG report said: “Staff indicated poor satisfaction with the quality of work and patient care they are able to deliver (and) low job satisfaction with work pressure.”

Compared with similar trusts, relatively few would recommend it “as a place to work or receive treatment”.

The CCG report also highlighted serious incidents requiring investigation (SIRIs) as an area in need of continued monitoring.

It said: “SIRI closure rates have improved but the quality team have identified themes of concern in SIRI root cause analysis investigations.”

When things go wrong, the CCG wants to be confident that lessons are being learnt.

It added: “There is a trend in line with national findings that shows reduced numbers of suicides in in-patient settings but increased numbers for individuals under the care of Crisis Resolution Home Treatment Teams.

“A peer review of ligature point risk and management has been followed up with a CCG quality team review of Mill View ward improvements and assurances secured from staff and service users.”

The teams caring for mental health patients in Brighton and Hove have been reorganised in the past few years.

The previous set up was criticised in reviews of the care in the community of Steven Dunne, a patient who killed his former housemate Gordon Stalker in Brighton three years ago.

An independent report, which refers to Mr Dunne as Mr B, said: “(Mr Dunne’s) care was not effectively managed. The team (caring for Mr Dunne) did not effectively assess the risk (that he) posed to the victim and potentially others.

“We believe that had it done so, it would have assessed (Mr Dunne) as being a high risk which should have triggered a risk management plan being put in place.

“An effective risk management plan that included options such as admission to hospital for further assessment, referral to the recovery team for the allocation of a care co-ordinator or allocation of his care to a specified person for more assertive support and a more detailed risk assessment may have prevented the homicide.”

It is inevitable that some patients will die whether they are being treated in hospital or in the community.

But part of the job of the CCG is to ensure that as far as possible it is commissioning good quality services so that patients are not more likely to die as a result of coming into contact with the NHS.

The report presented at Hove Town Hall can’t achieve that in itself. But it can be seen as a clear statement of intent and it shows how the CCG board means to do its job.

What do they look for?

Quality and safety in the NHS is measured in a variety of ways. A report to the CCG board said: “The quality indicators monitored range from formal reporting national data such as mixed sex accommodation breaches to ‘noise’ in the health economy that reflects on providers.”

The quality indicators used include patient experiences, including the number and seriousness of complaints, information provided by official watchdogs, legal claims and comments left on the NHS Choices website.

The CCG Quality Team also monitor clinical incidents, serious incidents requiring investigation (SIRIs) and alerts raised through formal channels. Hospital superbug (MRSA) rates are also analysed.

There are various measures of clinical effectiveness so that commissioners can decide whether medicines, surgery or other forms of treatment are having the desired effect.

The team looks at the culture within organisations such as workforce levels, vacancy and sickness rates, the use of agency staff and any trends that might have an effect on services.

And staff surveys are taken more seriously than many MHS workers probably realise.

Hot topics in the media come within another category of indicators and include issues that require health chiefs to have to make a public statement.

One example in the past year was about patients being discharged in the middle of the night. Although it was discussed in the national media, in Brighton it was an unusual occurrence.

It should be no surprise, given that the CCG is led by family doctors, that that feedback from local general practitioners (GPs) is also monitored.

The CCG board is chaired by long-serving local GP Dr Xavier Nalletamby.

Serious incidents

The CCG manages the serious incidents requiring investigation (SIRI) process for two of the three main trusts serving Brighton and Hove.

It also logs SIRIs on behalf of independent providers and private contractors.

Incidents are regarded as closed if

• A robust analysis has been evident
• An appropriate root cause has been identified
• A robust action plan is in place to address the root cause and any recommendations

Health chiefs hoped to close as many serious incidents as possible before the CCG took formal responsibility for the process.

The report to the CCG board said: “Currently there are approximately 30 (serious incidents) overdue for closure for Sussex Partnership Foundation Trust and 20 for Brighton and Sussex University Hospitals NHS Trust.

“Most of these have either not had an investigation report submitted or have been scrutinised and are ‘on hold’ pending further scrutiny.”

This could include waiting for a coroner’s inquest to be held or a police investigation to be completed.

Nursing homes

All nursing homes are expected to audit the quality and safety of the care that they provide.

A clinical quality review nurse carries out follow up inspections.

The results are signed off by the nursing homes and published on the CCG website and Brighton and Hove City Council’s website.

Homes are monitored for safeguarding alerts raised for residents while in their care. There are no outstanding concerns at present.

A CCG committee will receive quarterly reports showing the status and risks of nursing home beds jointly commissioned by the NHS and the council.

A report to the CCG board cautioned: “Capacity in the Quality Team hampers individual pro-active scrutiny of all non-NHS providers but the team provides support on quality issues to commissioning managers in their monitoring of provider contracts.”