Basildon and Thurrock University Hospitals NHS Foundation Trust Rapid Responsive Review – Key Findings and Action
Plan
Review into the Quality of Care & Treatment provided by
14 Hospital Trusts in England
July 2013
Contents
1.
Overview
3
2.
Summary of Review Findings and Trust response
6
3.
Risk Summit Action Plan
Appendices
Appendix I:
12
15
Risk Summit Attendees
16
2
1. Overview
A risk summit was held on 6 June 2013 to discuss the findings and actions of the Rapid Responsive Review (RRR) of Basildon and Thurrock University Hospitals NHS
Foundation Trust (“the Trust”). This report provides a summary of the risk summit including the Trust response to the findings and an action plan for the urgent priority actions
from the RRR discussed at risk summit. The action plan includes any agreed support required from health organisations, including the regulatory bodies.
Overview of review process
On 6 February 2013 the Prime Minister asked Professor Sir Bruce Keogh, NHS England Medical Director, to review the quality of the care and treatment being provided by
those hospital trusts in England that have been persistent outliers on mortality statistics. The 14 NHS trusts which fall within the scope of this review were selected on the
basis that they have been outliers for the last two consecutive years on either the Summary Hospital Mortality Indicator (SHMI) or the Hospital Standardised Mortality Ratio
1
(HSMR) .
These two measures are intended to be used in the context of this review as a ‘smoke alarm’ for identifying potential problems affecting the quality of patient care and
treatment at the trusts which warrant further review. It was intended that these measures should not be reviewed in isolation and no judgements were made at the start of the
review about the actual quality of care being provided to patients at the trusts.
Key principles of the review
The review process applied to all 14 NHS trusts was designed to embed the following principles:
1)
Patient and public participation – these individuals have a key role and worked in partnership with clinicians on the reviewing panel. The panel sought the views of the
patients in each of the hospitals, and this is reflected in the reports. The Panel also considered independent feedback from stakeholders related to the Trust, received
through the Keogh review website. These themes have been reflected in the reports.
2) Listening to the views of staff – staff were supported to provide frank and honest opinions about the quality of care provided to hospital patients.
3) Openness and transparency – all possible information and intelligence relating to the review and individual investigations will be publicly available.
4) Cooperation between organisations – each review was built around strong cooperation between different organisations that make up the health system, placing the
interest of patients first at all times.
1
Definitions of SHMI and HSMR are included at Appendix I of the full Rapid Responsive Review report published here http://www.nhs.uk/NHSEngland/bruce-keogh-review/Pages/published-reports.aspx
3
Terms of reference of the review
The review process was designed by a team of clinicians and other key stakeholders identified by NHS England, based on the NHS National Quality Board guidance on rapid
responsive reviews and risk summits. The process was designed to:


Determine whether there are any sustained failings in the quality of care and treatment being provided to patients at these Trusts.
Identify:
i.
ii.
iii.
Whether existing action by these Trusts to improve quality is adequate and whether any additional steps should be taken.
Any additional external support that should be made available to these Trusts to help them improve.
Any areas that may require regulatory action in order to protect patients.
The review followed a three stage process:

Stage 1 – Information gathering and analysis
This stage used information and data held across the NHS and other public bodies to prepare analysis in relation to clinical quality and outcomes as well as patient and staff
views and feedback. The indicators for each trust were compared to appropriate benchmarks to identify any outliers for further investigation in the rapid responsive review
stage as Key Lines of Enquiry (KLOEs). The data pack for the Trust is published at http://www.nhs.uk/NHSEngland/bruce-keogh-review/Pages/published-reports.aspx

Stage 2 – Rapid Responsive Review (RRR)
A team of experienced clinicians, patients, managers and regulators, following training, visited each of the 14 hospitals and observed the hospital in action. This involved
walking the wards and interviewing patients, trainees, staff and the senior Executive Team. This report contains a summary of the findings from this stage of the review in
section 2.
The two day announced RRR visit took place at the Trust’s main site on Tuesday 7 and Wednesday 8 May 2013 and the unannounced visit was held on the evening of
Sunday 12 May 2013. A variety of methods were used to investigate the Key Lines of Enquiry (KLoEs) and enable the panel to analyse evidence from multiple sources and
follow up any trends identified in the Trust’s data pack. The KLoEs and methods of investigation are documented in the RRR report for Basildon and Thurrock NHS
Foundation Trust. A full copy of the report was published on 16 July 2013 and is available online: http://www.nhs.uk/NHSEngland/bruce-keogh-review/Pages/publishedreports.aspx

Stage 3 – Risk summit.
This stage brought together a separate group of experts from across health organisations, including the regulatory bodies (Please see Appendix I for a list of attendees). The
risk summit considered the report from the RRR, alongside other hard and soft intelligence, in order to make judgements about the quality of care being provided and agree
any necessary actions, including offers of support to the hospitals concerned.
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The Risk Summit was held on 6 June 2013. The meeting was Chaired by Paul Watson, NHS England Regional Director (Midlands and East), and focussed on supporting the
Trust in addressing the urgent actions identified to improve the quality of care and treatment. The opening remarks of the Risk Summit Chair and presentation of the RRR key
findings were recorded and are available online: http://www.nhs.uk/NHSEngland/bruce-keogh-review/Pages/published-reports.aspx
Conclusions and priority actions
The RRR identified a number of areas of good practice, although these generally related to specific areas, wards or specialities. Therefore there was more for the Trust to do
in ensuring good practices were in evidence across the organisation, all of the time.
The Trust was deemed to be in significant breach by Monitor in 2009 as a result of concerns raised by the Care Quality Commission (CQC). These concerns included high
mortality indicators, poor infection control and concerns regarding clinical leadership. Since this period the Trust continues to have a 'red' governance rating and has had a
number of regulatory reviews since that date.
The Executive Team and staff recognised that the historical culture of the Trust was focused on financial targets and that finances were prioritised over quality. This was now
found to be a Trust undergoing significant transformation with a new Chief Executive, Medical Director and Chair.
The Executive Team interviewed recognised both the issues at the Trust and the need for change. The Chief Executive and Chair were clear that the tone at the top should
be one of long term sustainability and not short term solutions. As a result a transformation programme is underway. There was a lot to do within that and many priorities, for
which there needed to be an explicit plan (with timelines) to ensure all staff are aware of what is important and the pace of change.
Our review also identified a number of areas of outstanding concerns across all ten KLOEs. For the majority of areas we identified a number of improvements either already
underway at the Trust or planned actions. However, we included further recommended actions for each area including a number of areas of concern outstanding from the
July 2012 Silverman report. These included, for example, the presence of medical outliers and examples of infection control issues. The Trust responded positively to the
RRR process and implemented a number of immediate actions in response to the RRR feedback provided prior to the risk summit. Immediate action included improvements
in the implementation of NHS Professionals (NHSP) which had been escalated as a significant staffing risk by the panel.
No outstanding issues were therefore identified by the RRR that cause an immediate and significant concern to the quality of care and treatment at the Trust. Including the
one escalated issue, six areas were identified for discussion at the risk summit. These are summarised in the following sections and are detailed within the RRR report. An
action plan was agreed at the risk summit addressing all the urgent priority actions discussed.
Next steps
As the risk summit had focused on urgent priority actions, the Trust also agreed at the risk summit to provide a detailed action plan to all outstanding concerns and
recommended actions included in the RRR report by 27 June 2013.
Follow up of the RRR and risk summit action plan will be undertaken by other organisations within the system, including CQC and GMC visits. A formal follow up will consist
of a desktop review in October 2013 and a targeted one day site visit to the Trust in October or November 2013 reviewing key areas to understand the improvements that
have taken place. A report of the follow up findings will be issued to the risk summit attendees and will consider, if there are significant remaining concerns, if there is a need
to convene a further risk summit.
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2. Summary of Review Findings and Trust response
Introduction
The following section provides a summary of the RRR panel’s findings and the Trust’s response presented at the risk summit. The detailed findings are contained in the
Trust’s RRR Report. The Trust response was presented by Clare Panniker, Chief Executive, supported by Dr Celia Skinner, Medical Director, and Diane Sarker, Director of
Nursing. The agreed action plan in response to the urgent priorities is included in the following section.
Overview of Trust response
The Trust welcomed the review and its findings and recognised the issues identified. The Trust stated that the review confirmed the areas of concern that it was already
working on and signalled the need for clearer prioritisation and communication of its plans. The need for better arrangements for engaging with, listening to and responding
on patient feedback and experience was acknowledged.
The Trust stated that there were a number of existing strategic plans that will address the areas of concern which are coordinated in its Turnaround Plan – a Monitor licence
condition.
The Trust concluded that it was undergoing significant change with a clear determination to put quality and safety at the heart of all it does. Progress had been made in
engaging staff to develop its vision and values, from which all decisions were being guided. The Board was working on a new three to five year strategy for the organisation.
The Transformation programme would focus not only on the short term compliance issues, but also in creating longer term, sustainable changes to the culture and health of
the organisation and would be the vehicle for driving the change agenda. This was the start of a three year journey where the organisation needed to build an opportunity to
embed change, build trust and confidence and move out of the cycle of constant external reviews.
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Summary of Review Findings
1. Stability and prioritisation
There had been a number of changes to the Board over the last 18 months including the appointment of a new Chief Executive in September 2012 and a new Medical
Director in February 2013. The Trust established a new Clinical Director role on 1 April 2013, as part of the new clinically-led operational management structure which
has five clinical divisions, instead of the previous three. The Chief Executive and Chair have stated that they will regularly review the board to ensure, through its
development programme, that the Trust has the necessary skills, background and experience to lead the organisation on an ongoing basis.
Although the Trust is on a transformation journey members of the Board need to ensure that they close the gap between ward level and Board level, communicating and
engaging with the staff throughout. This should include being clear as a Board on the quality priorities and in communications with staff on transformation plans. The
Trust also needs to ensure that the effectiveness of the transformation is regularly evaluated, ensuring that patients remain at the heart of this improvement journey.
The Trust has been under scrutiny for some time and has undergone a number of reviews, including a number commissioned by the new Chief Executive, to gain an indepth understanding of the issues at the Trust. Historically the Trust has generally been viewed as a reactive organisation rather than proactive one when dealing with
issues and concerns. The Trust leadership now want to review current practices, understand issues and design solutions in a more proactive way so as to sustain the
required improvements. They are on an improvement journey and the next stage is, perhaps, the most challenging, requiring implementation and embedding changes
in practice - a period of stability is required to enable the Trust to deliver this challenging programme of transformation. Until this implementation and embedding is
complete, the effect of the changes cannot be assessed as appropriate.
Recommendation

Prioritisation of improvement plans – the panel noted a significant numbers of plans for improving quality of care and services currently in place at the Trust, in
response to the many reviews undertaken in recent years. The Trust needs to develop a single, prioritised action plan to focus on the key improvement areas noted
in this report.
Trust response
The Trust has agreed to take the following actions:



Develop a single, prioritised plan to focus on key improvement areas underpinned with a clear communication strategy for staff by the end of June 2013.
Board to ward review of governance and risk arrangements had been completed with new structures and processes implemented. This is to be clearly
communicated in June and July 2013.
Ward level quality data reported to the Board to be reinforced by a new monthly Nursing and Medical Director report and new structured arrangements for Executive
Director / Non Executive Director ward visits and feedback.
The Trust confirmed that external support was already in place through the Good Governance Institute with no further support required.
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2. Infection control
Whilst the panel observed examples of good practice in infection control during the visit, issues were also noted in some areas including a number of infection control
concerns identified on one ward observed.
Recommendation

Infection control – the Trust needs to ensure its infection control procedures are consistently applied in the organisation and undertake audits to gain assurance on
this area.
Trust response
The Trust has agreed to take the following action:

Review of infection control team in progress to ensure appropriate skills and Board review of infection control plan in July 2013 supported by enhanced divisional
accountability for compliance with policy and regular Clinical Commissioning Group (CCG) unannounced compliance assessments.
It was confirmed that external support had already been agreed with the CCG for regular unannounced compliance assessments.
3. Bed management and flows
The Trust has high activity levels as evidenced by performance data and the panel’s observations. Also staff and patients interviewed consistently spoke of how busy
the hospital was. Whilst the Trust Board members interviewed recognised the issue, we did not obtain evidence of a clear and prioritised plan to address the issues
with bed management. Throughout our visit we identified evidence of poor bed management and flows with an absence of real time patient tracking noted and multiple
patient location systems found to be in place. Review of Accident and Emergency (A&E) waiting times identified patients regularly breaching the four hour target.
It was noted that the area’s urgent care pathway work linked to the Trust’s capacity challenges and current plans did not provide assurance yet that the risks were being
fully addressed. Further work would be required by the Trust, NHS England area team and local CCGs to address this by the next plan submission in July 2013.
Recommendation

Bed management – the systems for bed management and patient flows need to be urgently reviewed and improved.
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3. Bed management and flows
Trust response
The Trust has agreed to take the following actions:

Agreement with commissioners to increase bed base by circa 64 beds by November 2013 as a time limited response to current demand while health and social care
economy develops integrated care pathways for the frail elderly.

Major programme ‘Right Place, Right Time’ implementing key efficiency and effectiveness measures including the development of ambulatory care model and
specialty level length of stay reductions. To be supported by new Electronic Patient Records (EPR) / Patient Administration System (PAS) from October 2013 with
real-time ‘bed boards’ being rolled out at the time of the risk summit.
The RRR panel requested that a further action be included to develop a ward level assurance programme. The Area Team will also continue to coordinate work around
the urgent care pathway.
4. Patient experience
Examples of good levels of patient care and treatment and good experiences of patients were identified. Whilst Board members interviewed spoke of knowing about
patient experiences, issues were noted with the lack of processes in place to ensure they monitor it regularly, including the Board not hearing patient stories, although
plans were in place for patient stories to be heard by the May Quality and Patient Safety Committee. It was also identified that the Board only receives details of
numbers of complaints and response times, not the detail of the complaints.
The panel found the location of PALS difficult to find and some comments were received from patients that the perception was that the PALS service was there to serve
the Trust and not patients.
The risk summit attendees requested that the Trust consider taking the patient story to Board, rather than a subcommittee. The Trust explained the rationale for the
decision taken including it being a smaller group and private session and that the Chief Executive had experience of the approach working successfully in the past. The
Trust acknowledged the challenge from the risk summit and agreed to review the decision and consider taking the patient story directly to Board.
The risk summit attendees requested an action to address the issue noted with the location of PALS and actions were agreed for short term improvements in signage
and installation of a phone line from the front door with longer term review of the location.
The overall patient experience and engagement issue was agreed by the risk summit to be a wider issue than just the Trust and an action was agreed for work across the
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4. Patient experience
local health system.
Recommendation

Action on patient experience themes – the Board needs to urgently review and understand what their patients’ views are and address key complaints themes.
Trust response
The Trust has agreed to take the following actions:





Patient experience lead to commence July 2013 and patient stories to be taken to the Quality and Patient Safety Committee from June 2013 with upward reporting
to Board.
Improved reporting of complaints – themes and actions to Board since May 2013.
Patient Liaison Service (PALS) enhanced by new clinical leadership since the review.
Regular dialogue with HealthWatch and ‘Cure the NHS Basildon’ – to listen and act on concerns.
Stakeholder review of complaints and PALS management to be undertaken in July 2013 (including consideration of Patient Panel effectiveness).
5. Staffing
The RRR panel observed passionate and caring staff including a number of staff attending the listening event as they wanted an awareness of the patient feedback. A
large number of staff observed appeared to genuinely care and want the best for their patients despite the high level of negative press and local criticism of the Trust.
A number of issues were noted by the panel with staffing levels and skill mix including junior doctor workload, particularly overnight, the use of escalation wards and
high number of outliers. Staffing levels were observed to not be consistently sufficient.
Recommendation

Staffing and skill mix – the Trust needs to review its current staffing levels for nursing and medical staff and action any changes required for improving quality and
safety of care.
Trust response
The Trust has agreed to take the following actions:
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5. Staffing

Nursing skill mix completed and additional funding agreed at May 2013 Board (£0.8m to be invested in 2013/14 in addition to £1m in 2012/13 to achieve 65/35
ratio).

Medical staffing review commenced through consultant and non-training grade job planning to facilitate consistent 7 day working. Likely investment in additional
respiratory team to support additional capacity and demand. Support requested for medical staff bench marking.

Hospital at Night model under development for phased implementation in November 2013 – a key ‘Right Place, Right Time’ work stream.
The risk summit chair ensured that the action plan included review of all nursing and medical staff numbers and skill mix and included actions to review, plan to address
issues and implement the action plans.
6. Implementation of NHSP
At the time of our visit, the Trust had recently implemented NHSP and a Steering Group had been in place to govern its implementation. Discussions with a number of
staff identified issues with the implementation. This was observed to be a significant risk to quality of care for patients during the visit and escalated to the Trust. It was
also identified that the Trust did not plan for the Steering Group to meet following implementation.
Recommendation

Implementation of NHSP – the Trust should demonstrate that implementation issues have been addressed. The Steering Group that had been in place to govern
the implementation of NHSP should continue to meet post implementation to closely monitor and manage NHSP.
Trust response
The Trust has agreed to take the following action:

NHSP issues addressed and operational management group in place.
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3. Risk Summit Action Plan
Introduction
The risk summit development of an outline plan focused on the urgent priority actions from the RRR report. No information in addition to the RRR report was presented at the
risk summit. The following section provides an overview of the issues discussed at the risk summit with the developed action plan containing the agreed actions, owners,
timescales and external support.
Action plan
Key issue
1.
Stability and prioritisation
Absence of stability in governance and
clear prioritisation of actions.
Agreed action and support required
Owner
Timescale
Trust
End of June 2013
Trust
End of July 2013
Board review of infection control plan
Trust
End of July 2013
Development of a ward level assurance programme
Trust
To commission external
support by end of June
The Trust are producing a single, prioritised action plan to focus on key improvement
areas, with a given timeframe and owner for these improvements. This will include a
clear plan to communicate to staff and stakeholders.
Good Governance Institute is already supporting the Trust
2.
Infection Control
Whilst the RRR panel observed examples
of good practice in infection control during
the site visit, the panel also observed
examples of infection control issues.
Issue is one of consistency of the
application of policies.
Review of infection control team in progress to ensure appropriate skills, experience
and numbers to support the Trust
The CCG is already supporting this through agreed unannounced compliance visits
The Trust would like national infection control expertise to support the Trust in
developing ward level assurance programme. Support to be provided by an external
expert identified by NHS England.
Interim report including forward
action plan by end of July 2013
3.
Bed management and flows
Development of the system Urgent and Emergency care plan
Area Team
End of July 2013
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Key issue
Throughout the RRR visit, the panel
identified evidence of poor bed
management and flows.
Agreed action and support required
Owner
Timescale
New EPR/PAS from October 2013 with real-time ‘bed boards’ being rolled out in
parallel along with training and staff engagement to enable real time patient tracking
Trust
By end of October 2013
Agreement to increase bed base by c64 beds
Trust
By end of November 2013
‘Right Place, Right Time’ project deliverables improving bed management and flow
including:

Hospital at Night model.

First stages of ambulatory care model.

Length of stay reduction plans at specialty level.
Trust
By end of October 2013
Plans to take a patient story to the Quality and Patient Safety Committee rather than
the Board will be reviewed following comments from the risk summit attendees and
an agreed process determined for the Board to understand patient experience
Trust
By end of September 2013
Board complaints reporting amended to include themes and actions
Trust
Completed May 2013
PALS signage to be improved and telephone line from the front door of the Trust to
PALS to be installed
Trust
By end of June 2013
Review of PALS location and decision on permanent location with business case for
that location including timetable for implementation
Trust
By end of September 2013
PALS service enhanced by new clinical leadership
Trust
Completed May 2013
Plan for overall review of how to engage with patients, both proactively and
reactively within the local health system
Area Team
By end of August
Experience in implementing Hospital at Night would be welcomed by the Trust.
Support to be provided by NHS England, Midlands & East
4.
Patient experience
There was no systematic Board
understanding of patient experiences and
evidence of action being taken to respond
to issues raised by patients.
CCG – Tom Abel
Area Team, CCG and HealthWatch to support the overall review of patient
engagement
Trust – Diane Sarker
13
Key issue
5.
Staffing
A number of issues were noted by the
RRR panel with staffing levels and skill mix
Agreed action and support required
Owner
Timescale
Review of Trust nursing levels and investment decision by the Board
Trust
Completed May 2013
Phased recruitment to address issues identified through nursing staffing review
Trust
By end of April 2014
Skill mix review of specialist nursing roles
Trust
By end of September 2013
Action plan to address issues arising from specialist nursing roles skill mix review
Trust
By end of October 2013
Implementation of actions to address issues arising from specialist nursing roles skill
mix review
Trust
By end of December 2013
Consultant job planning review covering consultants and middle grades
Trust
By end of July 2013
Consultant job planning review – plan to address issues identified
Trust
By end of August 2013
Consultant job planning review – filling of immediate gaps
Trust
By end of November 2013
Trust
Completed May 2013
Medical staff bench marking support to be provided by NHS England
See also 3 above action re Hospital at Night
6.
Implementation of NHSP
NHSP issues addressed and operational management group in place continuing
oversight and monitoring
Discussions with a number of staff
identified a number of issues with the
implementation of NHSP affecting the
management of temporary staffing.
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Appendices
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Appendix I: Risk Summit Attendees
Risk summit role
Risk summit chair
NHS England Regional Director (Midlands and East)
RRR panel chair
NHS England Regional Medical Director (Midlands and East)
RRR panel representative - Nurse
RRR panel representative – lay representative (public / patient
representative)
Name
Paul Watson
Dr David Levy
Fay Baillie
Asa’ah Nkohkwo
RRR panel representative
Graeme Jones
RRR panel representative
Finola Munir
Trust Chief Executive
Clare Panniker
Trust Director of Nursing
Diane Sarkar
Trust Medical Director
Celia Skinner
NHS England, Regional Dir Ops and Delivery
NHS England, Regional Chief Nurse
NHS England, Regional Deputy Medical Director
Sarah Pinto-Duschinsky
Ruth May
Alistair Lipp
NHS England, Regional Deputy Director of Nursing
Sylvia Knight
NHS England, Regional Deputy Director of Nursing
Lyn Mcintyre
Area Team (Essex) Director
Andrew Pike
Area Team (Essex) Director of Nursing
Pol Toner
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Risk summit role
Name
CCG Chief Officer Designate
Tom Abel
CCG Chief Operating Officer
Mandy Ansell
CCG Accountable Officer
Nimal Raj
CCG Executive Nurse
Lisa Allen
CQC Regional Director
Andrea Gordon
CQC Compliance Manager
Rob Assall
Monitor, Regional Director
Adam Cayley
HealthWatch Essex
Matt Fossey
Health Education East of England, Director of Education and Quality
Health and Wellbeing Board, Chair
Health and Wellbeing Board, Cabinet Member for Public Health
Prof Simon Gregory
Barbara Rice
Councilor Ann Naylor
Health and Wellbeing Board, Acting Director of Adults
Roger Harris
General Medical Council, East of England, Employer Liaison Advisor
Andy Lewis
Independent moderator
Recorder
Rachel Vokes
Randeep Nandhra
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