Oral Statement to the Assembly by Health Minister Edwin Poots – Tuesday 8 April 2014 – Promoting Quality and Good Governance across the HSC
Mr Speaker in recent weeks I have informed the Assembly about some serious failings in the quality of care provided to patients and the robustness of governance arrangements in both the Belfast and Northern Health and Social Care Trusts.
My approach in responding to those failings has been to find out what went wrong and to ensure that action is taken to correct it, as these are serious matters and deeply concerning for those patients and their families who have been affected by them.
In my previous Statements I said that I wanted to establish the facts concerning these failings and to take immediate, medium term and longer-term action to correct what went wrong and to ensure that the necessary learning would be applied across the entire Health and Social Care system in Northern Ireland. I will come on to further actions taken to address the specific failings in the Northern and Belfast Trusts shortly, after I outline for Members the key elements of my strategic approach to improving the quality of care provided to patients and the robustness of governance arrangements across the Health and Social Care sector in Northern Ireland.
There are three key elements to this strategic approach - they are:
- Review of unscheduled care;
- Staff Involvement; and
Unscheduled Care Review
Firstly, Members will recall that following the major incident at the Royal Victoria Hospital’s Emergency Department, declared by the Belfast Trust on 8 January, I commissioned the RQIA to conduct a systemic assessment of arrangements for unscheduled care in the Belfast Trust with a view to informing the wider picture regionally. That Review, which is currently underway, is being carried out by eminent professionals, each expert in their field of unscheduled care. Its remit is to examine the fundamental underpinning systems, processes, resources and model for unscheduled and emergency care including how we build sufficient resilience regionally.
At this point Mr Speaker I can tell Members that the Review Team has been working with the Belfast Trust to gain an understanding of the flows of patients to and within the hospitals in the Trust. A wide range of relevant information has been sought and provided by the Belfast Trust, the Health and Social Care Board and other HSC organisations including the Northern Ireland Ambulance Service.
Members of the Review Team have had a comprehensive briefing by the Chief Executive and Senior Executives of the Belfast Trust on the programme of changes which the Trust has been undertaking to improve hospital services in Belfast. During the next month, the Review Team will be visiting Trust facilities and meeting with frontline staff and managers. They will also be meeting with other organisations in relation to the wider regional aspects of the Review. The Chair of the Review Team has had initial visits to all Trusts including NIAS. He has advised that in every Trust there are examples of innovations designed to improve the flows of patients and their experience of the care provided.
Mr Speaker, the Review team will provide their report to me in June but I am not prepared to wait for receipt of the final report and recommendations in June, I want to see action now. I welcome therefore that to help share this learning across organisations, and to consider initial findings from the work of the Review Team, the RQIA will be holding two Summit events in May. The outputs from these events will help inform the recommendations of the final report of the Review which I have asked to be completed by mid-June.
The Review Team’s report will provide one of the three building blocks on which the improvement in the quality of patient care and governance arrangements will be taken forward.
I want to ensure that the need for best practice in unscheduled care to be maximised across the HSC, is addressed urgently.
I believe there is no better way to do this than to directly involve the staff who deliver that care and to empower them to act. Staff involvement is therefore the second building block on which I intend to deliver positive change. In that respect I participated in the Royal College of Nursing Emergency Care Summit on the 19th February where I heard at first hand the views of emergency nurses and their commitment to drive emergency care forward and improve care for our patients. Members will recall that in my Statement to this House on 18 March I announced that the College of Emergency Medicine had agreed to hold an Unscheduled Care Summit which will pull together information from a wide range of unscheduled care experts and foster action across the HSC.
This Unscheduled Care Summit, which takes place tomorrow, is about whole system solutions. I have said before that many of the solutions to the challenges in Emergency Departments will be found outside the door of the E.D. That is why I have asked the College to ensure that the Summit brings together some of the most senior representatives of Hospital Medicine, General Practice, Nursing, Social Work, Allied Health Professionals as well as managers and representatives of Trade Unions in Northern Ireland and charges them with looking at these issues systemically.
As I told this Assembly on 18 March, the College has also agreed to work with my Department and the wider HSC to hold a follow up event sixty days after the summit to build on the outcomes of the summit and develop recommendations on how to maximise the effectiveness of urgent and unscheduled care services in Northern Ireland. I expect that the Summit and follow up event will not only share vital learning but will also produce definitive proposals for my consideration in June of this year alongside and complementary to the RQIA’s report.
Mr Speaker, today I am announcing the third building block of my strategic approach to delivering the improvement that this Assembly and the public have asked for. I want to see if a step-change improvement in the quality of governance arrangements across the HSC is needed and whether these support a culture of openness and transparency; a culture of enquiry and learning; a culture of redress and making amends when we get things wrong. Subject to appropriate approvals I am commissioning external experts from outside Northern Ireland who have a high-level of expertise in the field to undertake a study to provide me with their independent advice on the effectiveness of these governance arrangements and how they can be further developed and strengthened.
In order to secure the best possible response for the population of Northern Ireland, an initial approach has been made to the former Chief Medical Officer for the Department of Health in England, Professor Sir Liam Donaldson. I am pleased to advise the Assembly that he has indicated that he would be willing to take up this assignment.
You will no doubt be aware that Professor Sir Liam Donaldson has extensive experience in healthcare. From 1998 to June 2010, Sir Liam was Chief Medical Officer for England and the United Kingdom’s Chief Medical Adviser and his record and achievements speak for themselves. Internationally, Sir Liam served as member and Vice-Chairman of the World Health Organisation’s Executive Board and conceived of, founded, and led the World Alliance for Patient Safety, an initiative that moved action on safety to a global scale. Terms of reference for this piece of work, which I expect will be completed by the end of the year, are appended to this Statement and are also available on the Department’s website.
Mr Speaker, my strategic approach to improving the quality of care and the effectiveness of governance in the HSC could not be clearer: three significant and serious building blocks to bring about improvement. One is already underway; the second will begin tomorrow and the third I have announced today. All involving eminent people, each expert in their field with wide experience of healthcare, all working to clear terms of reference and all are taking place within a coherent strategic approach and driven by my resolve and the determination and commitment of all in the health service.
While it is crucially important to learn from the past it is essential to look forward to the future and ensure that in learning from the past appropriate actions are taken to ensure delivery of high quality safe and effective services underpinned by robust governance across the whole health and social care sector. That is exactly what my strategic approach is intended to do and that is what I intend to deliver.
Developments at Trusts
Mr Speaker, I have made clear and demonstrated my commitment to openness and transparency in relation to our health and social care services. I have apprised this Assembly and the citizens of Northern Ireland of the serious issues in relation to the Northern and Belfast Trusts as soon as possible after I became aware of them. In that respect I want to take this opportunity to provide the Assembly with an update on matters relating to both Trusts.
In my Written Statement to the Assembly on 28 March I informed Members about the continuing work at the Northern Trust on the implementation of the Improvement Programme and about findings emerging from the second phase of implementation. Following the Statement there were a number of reports highlighting the pain and anguish suffered by the families of those patients who directly experienced the serious deficiencies in the quality of the care that they received.
As I indicated in my Statement on 28 March, I asked the Trust to confirm to my Department as soon as possible that all appropriate action such as initiating fuller investigations and making sure all affected patients and families are given the appropriate information and support has been completed. I also asked them to ensure that these individual cases have all been reported appropriately, properly investigated and that learning from those instances is effected within the Trust and more widely within the HSC as necessary. I want to update Members on the assurances that have been provided to me.
The Trust has advised me that they have informed the families in all twenty cases. I want to be clear here that I expect there to be meaningful engagement with families which includes giving them the opportunity if they wish to participate in the Serious Adverse Incident investigation. The families should be afforded sight of the final report and be informed of progress with the implementation of recommendations.
I am seeking assurances from the Trust that appropriate actions have been taken in all 20 cases to report to all relevant authorities, including the Coroner, to investigate the incidents to identify learning and to implement recommendations from completed investigation. Some of these investigations are still ongoing. I will be receiving regular updates in the future, and will keep Members fully informed.
Mr Speaker, on the matter of the Northern Trust I would, if I may, like to take this opportunity to clarify that the Turnaround team was appointed to the Northern Trust in December 2012, not in 2011 as I incorrectly indicated in responding to an Oral question in the Assembly on 31 March 2014.
Mr Speaker, in relation to the Belfast Trust, on Monday 10 February I delivered a Statement informing the Assembly of my instruction to the RQIA to carry out an inspection of the Emergency Department and Acute Medical Unit at the Royal Victoria Hospital over the weekend of 31 January to assess the quality of care and dignity afforded to patients in those facilities.
A Belfast HSC Trust document entitled ‘Improvement Plan for Unscheduled Care in Belfast Trust’, which is being published today on the Belfast Trust website, details the actions that have been taken to improve unscheduled care for patients.
The final report of the findings of the RQIA Inspection will also be published this morning. Despite the failings identified in this report one clear message also shines through, and that is the commitment of the staff to their patients.
Staff who are genuinely upset whenever they feel they have not, for reasons outside of their control, given the best care to their patients.
These are doctors and nurses, social workers and many other health professionals, porters and domestic staff and managers who are making enormous effort to ensure that the sickest and most vulnerable people are given priority and patient safety protected. My thanks and appreciation goes out to them all. The challenges are complex and some of the solutions will not be immediately deliverable.
When I made my Statement to the Assembly on 10 February I outlined the RQIA’s interim findings from its inspection. These interim findings are now fully reflected in the report published today.
I was deeply upset to hear of suggestions that dignity is not always afforded to those who die in our emergency departments. This cannot continue; this must change.
I was angry that people had experienced unacceptable levels of care, I was angry that staff did not feel supported in delivering the care they wish to. I was particularly angry at the suggestion that targets should come before patients.
This is unacceptable, and I cannot and will not tolerate it.
Mr Speaker in response to the findings of this report I asked the RQIA to secure from the Belfast Trust a detailed action plan setting out how they will address the failings and issues identified. That action plan, in the form of a ‘Quality Improvement Plan’ is included within the RQIA’s report and describes how the Trust is addressing all of the recommendations in the report.
The document the Belfast Trust is today publishing complements and provides further details in relation to the Quality Improvement Plan in the RQIA’s report.
Following receipt of the RQIA report at the end of last week my officials met with the senior teams of the Belfast Trust, the Health and Social Care Board and the Public Health Agency to consider the RQIA’s recommendations and the Trust’s response, as set out in the Trust’s Quality Improvement Plan. At this meeting both the Health and Social Care Board and Public Health Agency confirmed that the Trust’s Improvement Plan was a reasonable response to the findings and recommendation in the report. The RQIA has also confirmed that it has accepted the appropriateness of the Trust’s Quality Improvement Plan in relation to taking forward the recommendations of its report.
This Improvement Plan presents an opportunity to improve the service and give better care to patients. It is critical that this plan is implemented without delay and I have advised the Trust of my clear expectations in this regard. I have also assured the Belfast Trust that it will have the full support of myself, my department, the Health and Social Care Board and Public Health Agency in taking forward this challenging agenda.
My Department was also updated on the immediate actions taken by the Belfast Trust following its meeting on 5 February with the RQIA at which it was presented with the RQIA’s interim findings. Details of the immediate actions being taken by the Trust were included in my Statement to the Assembly on 18 March and I am pleased to provide a further update namely:
- the completion of a nursing workforce review, which as I announced in my statement of 18 March, has resulted in the appointment of 15 additional nurses in ED and 25 in the Acute Medical Unit. This increase in nursing staff will permit, for example, an increase in the nurse to patient ratio in the resuscitation area to 1:1 and an increase in the number of nurses to four in the focussed assessment area at all times; in respect of the AMU the additional staff will facilitate a greater level of personal care and assistance with nutrition.
- The Trust’s Chief Executive and senior team have reinforced to staff directly that patients must be admitted to beds on the basis of clinical priority not targets. There will be senior management cover for evenings and weekends to provide support and guidance for staff and aid the flow of patients.
- The Trust in partnership with Trade Unions immediately provided support clinics in the Emergency Department and Acute Medical Unit to give immediate support to all staff working in these pressurised environments. The support team was made up of senior experienced nurses, occupational health staff, human resources staff and Trade Union colleagues.
- A review in respect of support services has been completed. This has resulted in a dedicated portering team based in the Emergency Department 24 hours each day every day.
- There are enhanced cleaning services in place with dedicated cleaning staff for the emergency department until 10 pm with further services then available from the night cleaning team until 7am.
- Additional catering provision is in now in place which is overseen regularly by the catering manager / supervisor. Supplies of water, tea and coffee and light snacks are available in the department at all times and emergency stores are readily available for times of surge.
- Security is readily available 24hrs each day.
- A learning and development / support programme is in place for all new nursing staff to ensure they have appropriate levels of training and induction to support them in their new roles.
- The Trust is establishing systems to ensure that staff receive feedback on any safety concerns which they raise including through team meetings.
- Additional senior nurses for ED and AMU have been appointed to oversee clinical care.
- An associate Director of Nursing for Unscheduled Care is to be appointed.
- An ED Clinical Lead for Safety & Governance is being appointed.
- The use of internal transport with nurse escort to improve timely transfer between sites.
- A direct assessment and admission facility for Frail Elderly on level 7, BCH is in place.
- The Trust will ensure that additional stocks of pillows and blankets are held and are available to the sister/charge nurse for times of increased requirement - these will be ordered and stocks overseen by the ward sisters.
- The Trust has reviewed and is in the process of procuring the necessary additional patient equipment such as cardiac monitors, IV pumps etc.
- The functions of the Acute Medical Unit have been clarified and additional arrangements such as a 4pm meeting between Patient Flow co-ordinator and Senior Medical decision makers have been put in place; and
- Additional administrative support to ensure 24/7 clerical support in AMU has been put in place.
As I advised in my Statement of 18 March this action has built on the initiatives already taken by the Trust following the recommendations in the review of the Emergency Department carried out by the College of Emergency Medicine last year details of which were included in my Statement of 18 March.
While the actions in the Trust’s improvement plan will improve the experience of patients using the Emergency Department and the Acute Admissions Unit in the RVH, the Trust cannot at this time guarantee that the Manchester Triage diagnostic timescales for patients who present at the Emergency Department will be adhered to at all times.
This is due to the inability to fill medical posts and has the potential to impact on the care provided to patients at times when the Emergency Department is under pressure if seriously ill patients wait longer than recommended. This issue has been recognised by the Trust and has been included in the Trust’s risk registers and appropriate mitigating action is in place which is monitored by the Trust and the Health and Social Care Board.
While I am looking to the Belfast Trust to ensure that a consistent approach is taken to the implementation of its Quality Improvement Programme, Members can be assured that those bodies with responsibility for commissioning and regulating the health service will remain vigilant in discharging their responsibilities as we move forward and I shall be seeking their assurance that progress continues to be made, that things have improved and that momentum is maintained.
Mr Speaker, I have previously referred to the five Serious Adverse Incidents (SAIs) related to the quality of emergency care provided by the Belfast Trust. These incidents caused all of us to have concern about the quality of governance in the Trust. My Department wrote to the HSCB in February 2014 to ask them to review completed Emergency Department linked SAI investigations to ascertain-
- whether delay may have been a contributory factor;
- the involvement of families and carers in the investigation process; and
- the involvement of the Coroner’s service
This work which will cover Serious Adverse Incident investigations between 2009 and 2013 is underway and it is anticipated that it will be completed by the end of April/early May. I have updated the Chair of the Health Committee on this timeframe and will provide a further update to the Committee once the analysis is available.
Whilst I am confident that our services are overwhelmingly safe, delivering better outcomes than ever and that the experience of the vast majority of patients, clients and their families is a positive one, there is clearly a need to provide greater independent assurance on the safety of services. Throughout the rest of this year RQIA will continue with a series of planned reviews including a review focussing on the experience of older people in acute care, a separate review focussing on discharge arrangements from acute hospitals and a review focussing on the implementation of the regional stroke strategy.
In addition, as part of a significant change to the work programme of the RQIA I have decided that the RQIA will from 2015/16 onwards undertake a rolling programme of inspections of the quality of services in all acute hospitals in Northern Ireland each year. Currently, inspections of acute hospitals arelimited to hospital infection prevention and hygiene. These inspection reports will be published by RQIA on a hospital by hospital basis as they are completed and will focus on a range of quality indicators around triage, assessment, care, monitoring and discharge. Members will appreciate the importance linkages between the programmes of work already scheduled and the further work I have now asked RQIA to undertake.
In the interests of openness and transparency and in order to provide reassurance where possible I have instructed all six Trusts that they must by the end of September 2014 review all Serious Adverse Incident Reports completed between January 2009 and December 2013 and provide information to my Department covering:
- their engagement with families;
- in cases where patients or clients died, their compliance with statutory requirements to inform the coroner;
- confirming that escalation and reporting to other organisations has happened appropriately; and
- if there are any general or specific issues – reporting any not previously identified which should be brought to my attention.
Whilst this work will initially be undertaken by Trusts themselves, the Health and Social Care Board, given its responsibilities for Serious Adverse Incidents, as well my Department, will consider any findings. The RQIA, as part of a planned review of adverse incident management, reporting and learning will, later this year, independently investigate and quality assure the work which each Trust has undertaken as part of this exercise. The RQIA will also, as part of the same planned review, consider the appropriateness of Trusts’ systems for identifying Serious Adverse Incidents by considering their current arrangements for reporting and handling adverse incidents, Litigation cases and Complaints. This will involve RQIA sampling cases from the adverse incidents, complaints and litigation systems and reviewing Trusts systems for identifying, where appropriate, these cases as SAIs. This work will complement and support the wider governance review that I am commissioning.
Analysing Hospital Deaths
Whilst a number of reviews and investigations will be ongoing it is important that we should continue to implement improvements which have already been identified. Today I have given the go-ahead for the phased regional implementation of an enhanced assurance process for all deaths in hospitals in Northern Ireland. This Mortality and Morbidity Review System (M&MRS) which is being developed by the Belfast Trust will be rolled out across Northern Ireland hospitals over a three year period and will record, review monitor and analyse all hospital deaths.
This system used effectively will provide additional scrutiny of the Death Certification process; enhance a culture of learning across Trusts; improve reporting of Serious Adverse Incidents where a death has occurred; act as an additional safeguard to ensure that deaths are appropriately reported to the Coroner; and improve the quality of information provided both to the Coroner and as part of Serious Adverse Incident notifications.
Rolling out this system will ensure that the causes of death are accurately recorded, reviewed and analysed thereby facilitating the identification of poor care management, learning from errors, openness and transparency, and improvements in patient safety and care.
This will not only provide a means by which to quality assure information on deaths at hospital level but will provide additional assurance and oversight in line with statutory responsibilities and ensuring the identification and sharing of learning from all deaths that occur in our hospitals.
Mr Speaker, I am in no doubt that the incidents and revelations of recent weeks have dented the reputation of our health service and have caused distress for those patients and their relatives who have been directly affected. I hope that the actions I have set out in this Statement will provide reassurance and alleviate the worry that has been caused to many.
In conclusion, I want to assure the Assembly and the public that I am committed to ensuring that the quality of care provided to patients coupled with the corporate governance that underpins care is the best it can be and to ensure that we have a mindset across the HSC that will deliver this. All of the action that I have taken in recent weeks and the further action that I have announced today are designed to give assurance that the provision of high quality care and robust systems and procedures are the routine day to day business of the HSC and when failings do occur these are quickly identified and rectified with openness and transparency. I believe that the facts to be established by the reviews to report later this year will confirm this to be the case however I also want to ensure that we learn from recent experience and refocus or redirect our efforts where necessary. I am confident that the strategic building blocks that I have put in place will deliver over time a step change improvement in the quality of care provided to patients and the quality of governance arrangements across health and social care in Northern Ireland.
I commend this Statement to the House.