The Francis Report and LINks/Healthwatch

The “Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry chaired by Robert Francis” – aka ‘the Francis Report’ – was published last week.

If you work in health, or patient involvement, then you must at the very least read the Executive Summary. It is very readable and concise and I’d recommend you print off a copy for bedtime reading and scribble on it.

I’m publishing on this blog the particular points that I think that LINks/Healthwatches need to read, digest, ponder and respond to. I think they are really important (and in fact, I’ve copied these paragraphs and put them in our LINk Legacy Document to be passed on to Healthwatch Somerset).

N.B. For the full chapter looking at patient involvement, you need to read Chapter 6 of Volume 1 of the full report.

Extracts from The Executive Summary:

The voice of the local community

  • 1.17 It is a significant part of the Stafford story that patients and relatives felt excluded from effective participation in the patients’ care. The concept of patient and public involvement in health service provision starts and should be at its most effective at the front line.
  • 1.18 Analysis of the patient surveys of the Trust conducted by the HCC and the Picker Institute shows that they contained disturbing indicators that all was not well from long before the intervention of the HCC.
  • 1.19 Community Health Councils (CHCs) were almost invariably compared favourably in the evidence with the structures which succeeded them. It is now quite clear that what replaced them, two attempts at reorganisation in 10 years, failed to produce an improved voice for patients and the public, but achieved the opposite. The relatively representative and professional nature of CHCs was replaced by a system of small, virtually self-selected volunteer groups which were free to represent their own views without having to harvest and communicate the views of others. Neither of the systems which followed was likely to develop the means or the authority to provide an effective channel of communication through which the healthcare system could benefit from the enormous resource of patient and public experience waiting to be exploited.
  • 1.20 Patient and Public Involvement Forums (PPIFs) relied on a variably effective, locally provided infrastructure. The system gave rise to an inherent conflict between the host, which was intended to provide a support service but in practice was required to lead with proposals and initiatives offered to lay members, and members of the forum, who were likely to have no prior relevant experience and to be qualified only by reason of previous contact with the hospital to be scrutinised.
  • 1.21 In the case of the Trust’s PPIF, the evidence shows quite clearly the failure of this form of patient and public involvement to achieve anything but mutual acrimony between members and between members and the host. A preoccupation with constitutional and procedural matters and a degree of diffidence towards the Trust prevented much progress.
  • 1.22 If anything, local Involvement Networks (LINks) were an even greater failure. The, albeit unrealised, potential for consistency represented by the Commission for Patient and Public Involvement in Health (CPPIH) was removed, leaving each local authority to devise its own working arrangements. Not surprisingly, in Stafford the squabbling that had been such a feature of the previous system continued and no constructive work was achieved at all.
  • 1.23 Thus, the public of Stafford were left with no effective voice – other than CURE – throughout the worst crisis any district general hospital in the NHS can ever have known.
  • 1.24 Under the new reforms, local healthwatch is intended to be the local consumer voice with a key role in influencing local commissioning decisions through representation on the local Health and Well-being Board. They will be expected to build on existing LINks functions. The responsibility for establishing Local Healthwatch will rest with the local authorities in the same way as it had for LINks. As is the position with LINks, the DH does not intend to prescribe an operational model, leaving this to local discretion. It does not prejudice local involvement in
  • the development and maintenance of the local healthcare system for there to be consistency throughout the country in the basic structure of the organisation designed to promote and provide the channel for local involvement. Without such a framework, there is a danger of repetition of the arguments which so debilitated Staffordshire LINks.
  • 1.25 The local authority scrutiny committees did not detect or appreciate the significance of any signs suggesting serious deficiencies at the Trust. The evidence before the Inquiry exposed a number of weaknesses in the concept of scrutiny, which may mean that it will be an unreliable detector of concerns, however capable and conscientious committee members may be.
  • 1.26 Local MPs received feedback and concerns about the Trust. However, these were largely just passed on to others without follow up or analysis of their cumulative implications. MPs are accountable to their electorate, but they are not necessarily experts in healthcare and are certainly not regulators. They might wish to consider how to increase their sensitivity with regard to the detection of local problems in healthcare.
  • 1.27 There are a wide range of routes through which patients and the public can feed comments into health services and hold them to account. However, in the case of Stafford, these routes have been largely ineffective and received little support or guidance.
  • 1.28 Local opinion is not most effectively collected, analysed and deployed by untrained members of the public without professional resources available to them, but the means used should always be informed by the needs of the public and patients. Most areas will have many health interest groups with a wealth of experience and expertise available to them, and it is necessary that any body seeking to collect and deploy local opinion should avail itself of, but not be led by, what groups offer.

Extract from the Table of Recommendations:

  • Patient, public and local scrutiny
    145 Structure of Local Healthwatch There should be a consistent basic structure for Local Healthwatch throughout the country, in accordance with the principles set out in Chapter 6: Patient and public local involvement and scrutiny.
  • 146 Finance and oversight of Local Healthwatch
    Local authorities should be required to pass over the centrally provided funds allocated to its Local Healthwatch, while requiring the latter to account to it for its stewardship of the money. Transparent respect for the independence of Local Healthwatch should not be allowed to inhibit a responsible local authority – or Healthwatch England as appropriate – intervening.
  • 147 Coordination of local public scrutiny bodies
    Guidance should be given to promote the coordination and cooperation between Local Healthwatch, Health and Wellbeing Boards, and local government scrutiny committees.
  • 148 Training
    The complexities of the health service are such that proper training must be available to the leadership of Local Healthwatch as well as, when the occasion arises, expert advice.
  • 149 Expert assistance
    Scrutiny committees should be provided with appropriate support to enable them to carry out their scrutiny role, including easily accessible guidance and benchmarks.
  • 150 Inspection powers
    Scrutiny committees should have powers to inspect providers, rather than relying on local patient involvement structures to carry out this role, or should actively work with those structures to trigger and follow up inspections where appropriate, rather than receiving reports without comment or suggestions for action.
  • 151 Complaints to MPs
    MPs are advised to consider adopting some simple system for identifying trends in the complaints and information they received from constituents. They should also consider whether individual complaints imply concerns of wider significance than the impact on one individual patient.

Other useful links:

What to do with this data:

  • Read it and digest it.
  • Circulate it to your LINk volunteers and colleagues.
  • Consider how you will respond to the recommendations and lessons learned.
  • Ask your local CCG and providers how they are responding to the recommendations.

Patient Inspections and Local Healthwatch: from PEAT to PLACE

There’s a lot of new Healthwatch info being published  – check out the new Healthwatch website at www.healthwatch.co.uk  – and one of the many new tasks for Local Healthwatch is involvement with new patient-led inspections. The info about this seems a bit fragmented, so to be nice and helpful I thought I’d try to summarise it here.

Patient-led inspections?! How did that sneak into my Healthwatch basket?!

David Cameron announced in January of this year that current PEAT (Patient Environment Action Teams) inspections would be replaced by new patient-led inspections, which will be known as Patient-Led Assessments of the Care Environment or PLACE.

What are (… were … ) PEAT inspections?

PEAT inspections, as they are known, have been going on since 2000. PEAT stands for ‘Patient Environment Action Teams’.  PEAT Teams are made up of NHS staff (such as nurses, matrons, doctors, catering managers, directors etc.) and also patients and patient representatives.

PEAT inspections are an annual event for all NHS sites that have more than 10 beds.  The PEAT teams look at non-clinical aspects of patient care – such as the environment, food, privacy and dignity – basically everything from how clean the floor is to how tasty the jelly is…

NHS sites and trusts are given scores from 1 (unacceptable) to 5 (excellent). The idea is that the inspections produce scores for each site to encourage them to improve their services – and to share best practice.

How are the new PLACE assessments going to work?

The final details haven’t been decided yet – but the new assessments are being piloted this October. A total of 68 hospitals are currently involved in pilot PLACE assessments. The Pilot assessments will run from 1 October to 12 October 2012. You can read the documentation that the hospitals have been sent here. They will be similar to the current PEAT inspections but with more lay members/patients on the teams (over 50% of the team members must be patients).

How will Local Healthwatch be involved?

Local Healthwatch will of course be the ‘new consumer champion for health and social care’ – and hopefully a source of eager patient representatives champing at the bit to do This Sort Of Thing. Local Healthwatches – like LINks – will decide what work they get involved with  so they might decide that they don’t want to get involved with the new PLACE assessments. But the initial message seems to be that Local Healthwatch should be invited to have a key role in the new PLACE assessments.

Which hospitals are taking part in the Pilot PLACE assessments?

Here’s a list of all the hospitals that are taking part (the list names the Trust and then the name of the hospital):

  • Sheffield Children’s, Sheffield Children’s
  • Salisbury NHSFT, Salisbury
  • Avon And Wiltshire, Callington Road
  • Worcester Acute, Redditch
  • Birmingham And Solihull, Ardenleigh
  • Royal Wolverhampton, New Cross
  • Sheffield Teaching, Northern General
  • Manchester Mh And Sc, Park House
  • Morecambe Bay NHS FT, Royal Lancaster
  • Leeds Teaching, St James
  • Devon Partnership, Langdon
  • Leicestershire Partnership, Evington Centre
  • Nuffield, Plymouth
  • Pennine Care, Fairfield General
  • S/W Yorkshire Partnership, Fieldhead
  • Bmi, Rochdale
  • East Cheshire NHS Trust, Congleton
  • Yeovil District NHSFT, Yeovil District
  • Bedford Hospitals NHS Trust, Bedford
  • Barking Havering And Redbridge, Queens Hospital
  • Chesterfield Royal NHS FT, Chesterfield Royal
  • Queen Victoria, Queen Victoria
  • West London Mh, St Bernards
  • Norfolk And Suffolk NHS FT, Hellesdon
  • Birmingham Women’s, Birmingham Women’s
  • Pennine Acute, North Manchester
  • South West London And St Georges, Springfield
  • Norfolk And Norwich, Norfolk And Norwich
  • Kent And Medway Partnership, Thanet
  • West Kent , Gravesham
  • Uclh, Heart Hospital
  • Southern Health, Parklands
  • York Teaching, York
  • Royal Brompton, Royal Brompton
  • Royal Liverpool And Broadgreen, Royal Liverpool
  • North Cumbria University, Cumberland Infirmary
  • Central And N/W London, Park Royal
  • Spire Healthcare, Harpenden
  • Western Sussex, St Richards & Worthing
  • Central Manchester, Central Manchester
  • Medway Maritime NHSFT, Medway Maritime
  • Dorset Healthcare, Blandford
  • Gloucestershire, Cheltenham General
  • South Tees, Friarage Hospital
  • University Hospitals Bristol, St Micheals
  • Southport And Ormskirk, Ormskirk
  • South Warwickshire NHS FT, Leamington Spa
  • Liverpool Heart And Chest, Liverpool Heart And Chest
  • Tees Esk And Wear Valley, West Park
  • Nottingham University, Nottingham City
  • Humber NHS FT, East Riding Community
  • Barts Health, Whipps Cross
  • Cambridge University Hospitals, Addenbrookes
  • North Staffs Combined, Harplands
  • Plymouth Hospitals NHS T, Derriford
  • 5 Boroughs Partnership, Hollins Park
  • Royal National Orthopaedic, Stanmore
  • Ramsay Healthcare, Colchester
  • Anglian Community CIC, Clacton And Harwich
  • Calderstones Partnership, Calderstones
  • Surrey Community, Woking Community
  • St Georges Healthcare, St Georges
  • County Durham And Darlington (Ex County Durham PCT), Richardson Hospital
  • Nottinghamshire Healthcare, Rampton High Secure
  • Leicester University, Leicester Royal
  • Papworth Hospital NHS FT, Papworth
  • South Staffordshire An Shropshire Healthcare, St George’s
  • Hinchingbrooke Healthcare, Hinchingbrooke
  • County Durham And Darlington NHS FT, Darlington

Some useful links:

What to do with this data:

  • Make sure your LINk understands that PEAT inspections are changing and – once established – Local Healthwatch should be offered the chance to be involved in the new PLACE assessments.
  • Check the list of Pilot areas to see whether your local hospital/s are involved. If so, get in touch with the hospital (ask for someone with ‘Director’ and ‘Nursing’ in their job title…) to ask whether you can be a part of the Pilot – or at least kept informed of developments.

NHS Frontline cuts

There’s been a fair bit of news coverage about cuts to staff in NHS organisations.  There is a lot of attention about this because the conservative party pledged not to cut frontline NHS staff during the election campaign. So the first thing to bear in mind is that these figures are hot potatoes that are being tossed about by all sides in the argument. There are hundreds of commentators discussing these figures, for example, this article from media agency ‘eGov monitor’.

NHS savings and cuts
The NHS has to save £20 billion by 2014.  This is to enable the NHS to balance the books, as there is an aging population which requires more health services, and a higher drugs bill because of scientific advances in medicines and treatments. This £20 billion was set out by the Labour government in 2009 and reaffirmed as the plan of action by the coalition government in their spending review.

The programme to drive this savings plan is called ‘QIPP’ – Quality, Innovation, Productivity and Prevention.  Each trust has its own QIPP plans, which detail how it will save money over the next few years.

What are frontline staff? Definitions of ‘clinical’ and ‘non-clinical
When looking at job loss figures, roles are usually divided into clinical and non-clinical staff. Clinical staff may be doctors, nurses, midwives, Health Care Assistants (HCAs), consultants, dentists, pharmacists, and other staff members who are involved in the direct care of patients. These may also be referred to as ‘frontline staff’.

Non-clinical staff includes staff who are receptionists, catering staff, cleaners and janitors, administrators and staff working in a non-clinical job such as Human Resources or various management and administrative roles.  (Not all managers are non-clinical though, of course – many managers, such as Matrons, are clinical staff.)

Frontline First website:
The Royal College of Nursing has been running a Frontline First campaign. The idea of the campaign is to speak out about frontline cuts and propose alternative ideas for saving money while protecting patient safety:

Frontline First will empower nursing staff to speak out against the NHS cuts that are harming patient care, expose where they see waste in the system and champion nurse-led innovations and ideas that are saving money whilst keeping patients safe.

To find out what information they have in your area, click on the interactive map over your area, and then click on ‘read more’.

False Economy website:
Another interesting resource is the ‘False Economy’ website at www.falseeconomy.org.uk. This ‘anti-cuts’ website is backed by the TUC.

You can click on your area and view the information that they have about your local services.

The False Economy campaign has recently undertaken a piece of research into cuts in health services. This research looked at responses to Freedom of Information requests put to health service trusts and shows over 50,000 job losses. Here’s an article that they’ve put together about their research.

The False Economy NHS data is also published by my favourite source of facts-n-figures, the Guardian Datablog:

This data has also been turned into an interactive map by thedatastudio (and you know how I love interactive maps):

  • Interactive Map of NHS job cuts
    You can click on your area of this map and see what data has been released under the FOI requests. (Bear in mind that if trusts show no job losses, this may be because they have not responded to the FOI requests, not necessarily because they are not losing any positions.)

What you can do with this data:
Have a good look through the websites above and make sure you know what information has been released by your local trusts about job losses.

Frontline, back-end or jiggling about in the middle – whatever the political arguments, a good healthcare organisation will be working with their LINk where changes are occuring that affect services to patients.  So keep your ear to the ground and make sure that where services are reduced or changed, you are confident that proper plans are in place to ensure that patient safety isn’t compromised.


Mapping 18-week Treatment Targets

You remember those nice chaps at Tactix4 who produced the interactive maps showing who was hitting their 4-hour A&E Targets? Well, as they promised, they have been fiddling with even MORE lovely maps, this time showing who is hitting their 18-week targets.

Check out this glorious 18-week Referral to Treatment Target Map.

Filter results by specialty!

Now you would have to have a heart of stone not to love this map. Not only can you see the general results for each Trust, but you can also drill down, using the handy drop-down menu, and see how each Trust is faring by specialty!  Go and have a fiddle RIGHT NOW!

What are these 18-week targets?

Along with the 4-hour target for A&E, the 18-week target is one of the main ways that local health service performance is measured.

The 18-week target meant that patients referred from a GP for further treatment (e.g. to a consultant) had to start that treatment within 18 weeks. This target was brought in because patients would sometimes have to wait a very long time (months or even years!) for treatment to start. An 18-week wait is still quite a long time – but this is the longest wait allowed. Many patients would be seen in a much shorter timeframe.

There is a good Q&A on the 18-week target on the NHS Choices website.

As I’ve mentioned before, these current targets are being replaced from April 2011 with eight new “clinical quality indicators”. These new indicators will include ‘patient experience’, ‘effectiveness of care’ and ‘patient safety’.

Have the 18-week Targets been scrapped then?
No, the 18-week targets have not been scrapped, but this target is no longer being ‘actively performanced managed’ and hospitals are no longer face penalties if these targets are missed.  But waiting times are not really supposed to be increasing. NHS chief Sir David Nicholson wrote in a recent letter to staff:

“Let me be clear that the government has stated its strong support for the rights in the NHS Constitution, which established patients’ right to access services within maximum waiting times or to be offered a range of alternative providers if this is not possible.”

So while this target may no longer be measured, referral for treatment within 18 weeks still remains a right for all patients.

Are waiting times in the NHS Constitution?
Yes! The NHS Constitution became law in January 2010. It brings together in one place details of what staff, patients and the public can expect from the NHS. It sets out the rights of patients and makes clear what patients can expect from the NHS. This includes maximum waiting times.

(You can read a good summary of the NHS Constitution on the NHS Choices website.)

Where is the data on these maps from?
The data comes from the statistics provided by each Acute Trust, which are sent to the Department of Health each month. (See the DH page for this data.) (For more info about the Acute Trusts, see my previous post on the 4-hour A&E Target maps.)

The data on these maps is the ‘admitted’ data – i.e. it shows the wait for patients who were admitted for treatment. Tactix4 explain:

The performance map shows how long people have waited for treatment. The figures used are those relating to patients treated in the last month for which data is available. The figures reflect the specialty selected, and look at patients whose RTT pathways ended in admission for treatment.

Of course, lots of patients won’t need to be admitted, and will just be treated as outpatients.  Tactix4 are hoping to make this data available soon as well!

What to do with this data:
Have a good play with the maps. Find your local trust and see how it is performing against the 18-week target.  Green means that 100% of patients are being seen within the target; amber means that over 95% are seen within the target (95% is the old official ‘target’, so this is okay).  Red means that less than 95% are being seen within the target waiting times.

If you are receiving issues from members of the public about waiting times at a particular hospital, you could check this map for some more definitive data. And if your local Trust is missing its targets, then we need to find out why.

For the future, as I said with the 4-hour target maps, this sort of interactive mapping has huge potential for patient choice – for which Local HealthWatch will be responsible.

A patient might want to know which access to this sort of information in order to decide which A&E department to attend. ‘Do you want to be seen quickly?’ – then chose the hospital which meets waiting time targets. ‘Do you want a hospital with a good reputation?’ – then chose the hospital which has good reports on Patient Opinion… This gives you an idea of how the data might be useful for patients wanting to exercise choice.

So have a good look around these maps – and if you can think of ways that they can be made more user-friendly, or more useful for LINks, let me know and I will pass your ideas back to Tactix4!

Thanks again to Tactix4 for some fantastic mapping. 🙂


Mapping 4-hour A&E Targets

Tactix4 Performance Map

Tactix4 Map

I was recently rummaging around the internet when I came across a very cool map put together by healthcare software developers Tactix4. The map showed how hospitals were faring on their 4-hour Accident & Emergency targets by placing red, amber or green pins on an interactive map. (Acute Trusts release this information once a week.)

I dropped them an email saying that interactive maps are really my absolutely most favourite thing, and asking whether they could make this map a little more useful for LINks by showing a little bit of historical data on the map as well, so that we could compare the last week’s performance against previous weeks.  A lovely man called Dave Green replied and said he would give it a go! Dave is obviously the sort of chap who can’t quite resist fiddling with a good idea until he has cracked it, and two days later he’d produced the maps. And if there’s anything I love more than an interactive map, it’s an interactive healthcare software developer.

Cool Map 1: A&E 4 Hour Waiting Target Performance >>

Click on your local acute trust and see how it performed in the last week against the A&E 4 Hour Waiting Target. You will also see a link to the relevant page on Patient Opinion.

Cool Map 2: A&E 4 Hour Waiting Target Improvement >>

This map shows how your local acute trust’s performance compares to the previous four weeks. Green means it’s improved since last week, amber means it’s stayed the same, and red means that it’s got worse (it still might be within the targets, but it’s declined from the previous week). Hover over your local acute trust with your mouse and you will see the last 4 weeks’ performance, listed with dates.

What are these 4-hour waiting targets?
One of the key performance indicators set by the Department of Health for NHS hospitals over the last ten years has been ‘the 4-hour Target’.  This meant that a target percent of patients (originally 100% but rapidly revised to 98%) attending an A&E department must be seen, treated, admitted or discharged in under four hours.

Last year, the Department of Health announced that the 4 hour A&E target was to be scrapped, along with other targets – and immediately reduced the target from 98% to 95%.

From April 2011 the 4-hour target will be replaced with eight new “clinical quality indicators”. These new indicators will include ‘patient experience’, ‘effectiveness of care’ and ‘patient safety’ (and I am desperately wondering how many doughnuts I would need to send Tactix4 to persuade them to map those for us too…).

What is an Acute Trust exactly?
The figures on these maps are figures from ‘Acute Trusts’. Hospitals are managed by acute trusts. Acute trusts are responsible for hospitals’ services, finances, strategy, development, etc. and employ the staff that work in the hospital.

Most acute trusts will be responsible for just one hospital, and sometimes ‘acute trust’ and ‘hospital’ are used more of less interchangeably. Acute Trusts are also sometimes called ‘Hospital Trusts’. You will probably know what happens in your local area. Bear in mind, though, that some acute trusts are regional or national centres for more specialised care – and others are attached to universities, training healthcare professionals. They can also provide services in the community, for example through health centres, clinics or in people’s homes.

There is an excellent article summarising all the different sorts of trusts in the NHS on the NHS Choices website.

What to do with this data:
Have a look at your local area and compare the performance of your local trust against the 4-hour target. If you are receiving issues from members of the public about a particular hospital, this might be another indicator that things need looking into a bit more.

For the future, this sort of interactive mapping has huge potential for patient choice. For example, if Local Healthwatches have responsibility for giving information that facilitates patient choice, then a patient might want access to this sort of information in order to decide which A&E department to attend. ‘Do you want to be seen quickly?’ – then chose the hospital which meets waiting time targets. ‘Do you want a hospital with a good reputation?’ – then chose the hospital which has good reports on Patient Opinion. Of course, these specific targets won’t exist for much longer, but this gives you an idea of how the data might be useful for patients wanting to exercise choice.

So, while the 4-hour target might be on the way out, these figures are still useful for giving us an idea of current performance, and they’re definitely a great way of showcasing how useful interactive maps can be. Big thanks to Tactix4!