Agenda item

Purpose of the item:

These reports outline the backlogs for cancer and elective (planned) care across Surrey Heartlands and Frimley ICS, the progress made in addressing these and actions being taken to reduce further. In addition, it outlines the work being undertaken to increase diagnostic capacity.

Witnesses:

Professor Andrew Rhodes, Professor of Critical Care at the University of London and the Chief Medical Officer for Surrey Heartlands Integrated Care Board (SHICB)

Lucy Hetherington, Associate Director of Planned Carefor Surrey Heartlands Integrated Care Board

Alexander Stamp, Deputy Chief Operating Officer– Planned Care Frimley Heath Foundation Trust (FHFT)

Orlagh Flynn, ICS Programme Director Elective Care, deputising obo Stephen Dunn, Director of System Flow and Delivery (Frimley NHS Trust)

Key point raised during the discussion:

1. The Chief Medical Officer (SHICB) provided a brief introduction to the report about the elective delivery of the waiting lists relating to outpatient surgery, diagnostics, and cancer.

2. The Chairman referred to the serious impact on those on the waiting list for long periods, and that there were further challenges to waiting lists over the past 12 months due to industrial action in addition to the impact of Covid. The Chairman asked if Surrey Heartlands Integrated Care Board (SHICB) had a system in place to cope with this and asked what the outlook was. The Chairman also asked whether SHICB expected to bring their waiting lists back to the required standards and how confident they were that the data available was accurate. The Chief Medical Officer explained that waiting lists had not recovered since the Covid pandemic. Industrial action further impacted waiting lists. SHICB’s hospitals learnt to manage and mitigate industrial action over time. Industrial action had since finished, and it was hoped it would not continue. Waiting lists were expected to take several years to return to required standards. This involved aligning capacity against demand, ensuring the right staff, facilities and infrastructure was in place.

3. A Member asked if there were any outstanding patients waiting over 78-weeks that did not relate to patient choice or conflicting medical needs. If this was the case, the Member asked how these patients were being prioritised. The Chief Medical Officer (SHICB) noted that a year prior, SHICB had patients waiting over two years, but had been resolving some of these long waits. The current aim was to see all patients within 65-weeks. The 78-week wait time had broadly disappeared. There were still a few patients at this wait time, usually due to the complexity of a patient’s caseload. Patients were prioritised against clinical need, by treating the most complex and high-risk patients first. The aim to get all patients seen within 65-weeks by the end of September 2024 was expected to be achieved by the end of 2024. The next focus would then be to reduce the wait to 52-weeks by mid2025.

4. The Member referred to NHS Frimley Integrated Care Board’s (ICB) increased waiting list and its increase post-EPIC system implementation. The Member asked what actions were being taken by NHS Frimley ICB to manage and reduce the waiting lists, and when they would be under control and exceeding expected standards. The Member asked how NHS Frimley ICB was supporting patients with long waits to manage their conditions.  The Member also asked for consideration to be given to referrals for elective surgery usually being made when the condition was already causing serious pain and impact on daily life.

5. The Board Director of Healthwatch Surrey asked if regular feedback was received from patients on their waiting experience and what had worked well for them and if it would be improved. The Board  Director asked if it had been used to improve the quality of the wait journey.

6. The Deputy Chief Operating Officer (FHFT) explained that FHFT’s waiting list was increasing up until EPIC's implementation due to organisational pressure. FHFT had a challenging winter position with Urgent and Emergency Care (UEC) pressure, which put pressure on elective services and pathways. FHFT had improved coping with elective challenges. FHFT’ Heatherwood Hospital was a Getting It Right First Time (GIRFT) accredited elective hub which helped elective pathways. Changes in how EPIC handled referrals resulted in an unaccounted-for waiting list change. There was reduction in activity as FHFT’s team acclimatised to EPIC, which increased waiting lists. The waiting list growth over time was due to demand on some of FHFT’s services. FHFT understood their waiting list and had high-quality data, such as validation levels of waiting list size. FHFT took assurance in their position and waiting list accuracy. A challenge for FHFT was service demand. Covid caused a significant backlog and system pressure. FHFT reviewed services to assess demand and identify needed interventions. FHFT was reviewing services to understand the demand and interventions needed. Reducing waiting lists to constitutional standards would be a multi-year approach. A big organisational change and work with Integrated Care System (ICS) colleagues was in managing primary care demand. Intervention being reviewed and developed should bring improvements.

7. The Deputy Chief Operating Officer (FHFT) explained that FHFT was fairly active in communicating with patients regarding their position on the waiting list when they achieved a certain threshold. FHFT encouraged patients as part of this process to outline any concerns they had on the impact of their condition deteriorating. If a patient had concerns, FHFT’s general policy was that the patient should first visit their General Practitioner (GP) who had a route to expedite referrals to hospitals. The Deputy Chief Operating Officer (FHFT) was not fully cited on feedback from patients regarding the process, but was open to further discussions and review to what FHFT could do better.

8. Regarding SHICB’s Data Quality (DQ) issues, following the Cerner installation during 2023/24, which resulted in some patients waiting extended periods of time, the Vice-Chair asked if all DQ issues had been identified and asked what ongoing work was being done with NHS Trusts to identify and mitigate further DQ issues. The Chief Medical Officer (SHICB) explained that Guildford and Ashford & St Peter’s Hospitals NHS Foundation Trust had experienced serval difficulties with the Cerner system that led to DQ issues. Cerner was complex and needed a high level of training for staff. This training was not where it was needed during Cerner’s implementation which caused issues, and there was now a focus to ensure staff were properly trained to use the system. Several DQ issues were identified and resolved as part of this. It was unclear if all DQ issues were resolved, as some could still be unidentified. The priorities were to reduce waiting lists which made data validation easier and put in place staff training for Cerner ensuring appropriate controls and mitigations were in place. SHICB were confident they were in a better place than before but could not be certain other problems would not arise, as seen elsewhere in the country.

9. Regarding ensuring sufficient diagnostic capacity to support cancer and elective activity and reduce wait times, the Chairman asked how the committee could be reassured that the NHS England’s current expectation that no patient should wait more than 65-weeks for elective care by September 30 2024 had been met, and asked how it would continue to improve. The Chairman questioned if the target was not met, what was being done to accelerate this. The Chief Medical Officer (SHICB) noted that SHICB performed well in diagnostic capacity but recognised that earlier diagnosis enabled patients to be treated sooner. The national focus was to move much of SHICB’s diagnostics into the community. The Woking site was used to develop community, and the Caterham site was being utilised for community diagnostics. Space Belfry Shopping Centre in Redhill would potentially be used. The aim was to increase capacity and to enable earlier diagnosis, outside of hospitals. SHICB were looking to transform diagnostic delivery outside of hospitals closer to primary care colleagues, and simultaneously aim to increase capacity to deliver surgery. An elective operating site was being developed at Ashford hospital in line with government policy to split elective and emergency procedures. The Royal Surrey Guildford’s cancer centre was being redeveloped and its capacity was being increased to deliver interventions and reduce wait times.

10. The Chairman noted that NHS Frimley was in the process of building a new diagnostic and imaging centre at Frimley Park Hospital, providing 74 extra beds.

11. A Member asked if there was a timeline for SHICB’s plans. The Chief Medical Officer (SHICB) explained that the elective operating centre would be working by the end of 2024. The appointment of staff to this centre to fully utilise capacity was an ongoing process. Some staff groups such as the anaesthetic staff that were more critical than others, not only for their role but there was a shortage of such staff which might cause delays. The Ashford sites elective centre provided significant additional capacity in the system. SHICB was working with all their organisations, so capacity was not looked at just within an organisational boundary but across Surrey. Patients were beginning to be asked to move around to free capacity so they could be treated earlier.

12. The Member raised that collaboration was key and suggested it would be two years before waiting lists would be reduced to the expected level. The Chief Medical Officer (SHICB) explained that returning to the waiting list constitutional standards was a multi-year approach. National guidance was to return to these standards within the next parliamentary cycle, and within the next 4 years. There was not complete reassurance that this would be delivered in all parts of the country. Surrey’s waiting lists were reducing faster than anywhere else in the country, but there was still a long way to go.

13. A Member asked what some of the achievements in collaborative approaches had been, what difficulties remained, and how were improvements being achieved. The Chief Medical Officer (SHICB) explained that as SHICB developed the elective centre in Ashford, there was work occurring to ensure SHICB was reviewing their waiting lists across Surrey, rather than just within organisations and the hospitals. Waiting lists could then be segmented for example, by the geography, ethnicity and deprivation, to ensure inequalities across Surrey were addressed. SHICB had digital tools which were being developed, to improve the ability to move patients between different organisations to free-up capacity and treat patients more quickly.

14. A Member asked about what was required to meet the constitutional standard, referred to as the referral-to-treatment (RTT), up to the target of 92% of patients waiting no more than 18-weeks for referral to the first consultant-led treatment, and if this figure was accurate. The Member also asked what the main issues were in meeting the RTT target. The Chief Medical Officer (SHICB) explained it was expected to take 3 to 5 years to achieve the RTT target. The key was to reduce waiting lists, which stood at around 150,000 people. They needed to reduce to pre-Covid levels of around 90,000 people to be within or near the constitutional standard. Therefore, SHICB needed to treat more patients, which was part of the work to increase capacity to deliver interventions. Demand needed to be managed and understood. Surrey’s population was increasing, which also increased demand. Surrey County Council’s (SCC) data showed there would be another 30% of people aged 85 in Surrey by 2030. This age group accessed SHICB’s services most often.

15. The Vice-Chair asked about SHICB’s waiting well initiative that was introduced in Ashford and St Peter’s Hospitals NHS Foundation Trust (ASPH). The Associate Director of Planned Care explained that ASPH introduced a patient portal. Every 4-weeks there was a process where patients could be contacted. Patients could relay questions and concerns through a feedback mechanism. ASPH was seeking additional support for a wider multi-disciplinary team to support patients in the waiting process with pain management and other concerns. SHICB was looking at this across the system to pass on to other partners.

16. The Chairman raised that consideration needed to be given to the accessibility of communication. The Chairman asked what both SHICB and Frimley Integrated Care Board (FICB) were doing to ensure patients were getting valid communication with appropriate messaging around what they should be doing, particularly during the waiting period. The Chairman also raised that a large part of the population did not understand complex language and NHS acronyms. The Chief Medical Officer noted that communication was key. The patient portals were being introduced across SHICB’s organisations. Feedback indicated the patient portals were well-received and enabled access to correspondence. Whether individual communication was appropriate was challenging to understand. The use of plain English was important.. The Chief Medical Officer referred to a visit he had to a primary care service that had implemented Artificial Intelligence algorithms to correspondence, which translated GP’s referrals to plain English. Initial hospital feedback was that this improved the quality of referrals. Some people not able to access the NHS App were recognised, and hard-copy correspondence was still used.

17. A Member noted the importance of keeping patients informed. The Chief Medical Officer (SHICB) noted there was an expectation for patients to be kept aware of what was going on. The majority of SHICB’s patients got to sign appropriate consent forms and were communicated with after a procedure.

18. A Member asked how it would be ensured that patients with no digital awareness could still access their records. The Chief Medical Officer (SHICB) explained that hard-copy records were still used. There was work being undertaken to understand this patient group to support and use other communication methods.

19. The Chairman asked how SHICB worked with other organisations to deal with cancer and elective care backlogs, such as private hospitals and neighbouring NHS trusts, to make effective use of capacity. The Chief Medical Officer (SHICB) explained there was capacity in Surrey’s traditional NHS organisations. Capacity could be used in other NHS organisations outside of Surrey and in the independent sector, such as private organisations and other health organisations (profit or non-profit) within Surrey. A government policy was to utilise all capacity available. In the last few years, all SHICB’s organisations improved on utilising their assets, such as moving from a 5- to 6-day, and sometimes 7-day operating. The traditional 8-to-10-hour day increased to 10-to-12-hour days. A challenge was the staff’s ability to keep up with demand. As demand increased for the SHICB workforce, there was a risk of staff burn-out which could impact safe working. SHICB needed to maintain the balance in maximising use while also deploying its workforce safely.

20. The Chairman brought attention to Heatherwood Hospital and the GIRFT report, that showed running the same type of surgery consecutively had efficiency gains, underlining the benefits of an elective surgery centre, with emergency care arrivals not diverting the production line approach. The Chief Medical Officer (SHICB) noted SHICB was working on this. A modern estate that was well-kept and built for purpose enabled productivity gains. Some of the estates that SHICB organisations use to operate in were old and not maintained to expected standards, impacting on productivity.

21. The Chairman asked about the constraints of the estates and what the strategic approach was to deal with them.  The Chief Medical Officer (SHICB) explained that the strategic approach was to split SHICB’s elective planned care services away from their emergency sites. Secondly, the approach was to ensure there was adequate and well-maintained infrastructure in place, such as adequate air handling in operating theatres for well-maintained infection control. Financial support structures enabled this approach to occur in a timely manner.

22. The Chairman referred to the impact of the time a patient spent in hospital after an operation and asked what was being done around the hospital discharge process. The Chief Medical Officer (SHICB) explained that SHICB was moving many surgical interventions into day-case surgery, where a patient was discharged from hospital on the same day as their operation, which required the right facilities. This was done well in some parts of Surrey, but other areas did not have the amount of day-case infrastructure and support in place. SHICB also needed to ensure that processes within their hospitals were aligned to getting patients mobilised and home in a timely and safe manner. For example, an ambition was to get hip replacement surgical patients discharged within a day. Some parts of the country were achieving this at 70-80%, but SHICB had an average of 2.8 days for discharging these patients. The quicker patients were discharged the more support was needed outside of hospital to stop patients returning to hospital, which was a challenge.

23. Regarding physical estates, the Deputy Chief Operating Officer (FHFT) added that although FHFT had good and well-utilised estates, Frimley Park Hospital was impaired by Reinforced Autoclaved Aerated Concrete (RAAC) and had lost two theatres as a result. RAAC would be an ongoing challenge, up until the new hospital was built, which was planned for 2030. FHFT was working to mitigate the impact of RAAC, which often involved the use of Heatherwood Hospital. There was a RAAC multi-year programme of inspections.

24. In reference to the report the Chairman stated that SHICB was scrutinising the data in detail at a speciality level in relation to waiting times and asked if there were any issues identified. The Chief Medical Officer (SHICB) raised that the specialty area that had the biggest problem tended to be orthopaedics, such as hip, knee, and shoulder replacement surgeries. The volume of patients coming through to this area was more than could currently be managed, which further increased waiting lists. Another challenging speciality was optometry, specifically for cataracts surgery, due to a high volume of patients that outstripped demand. Therefore, additional capacity was being put into the elective site in Ashford. There were several other providers that came into this marketplace to provide support. Some of the major cancer pathways remained challenged due to complexity and rarity. The report highlighted the challenges concerning complex gynaecological procedures, especially for endometriosis, which required simultaneous co-ordination between different teams for a long period of time.

RESOLVED:

1. Surrey Heartlands NHS ICB to clearly communicate learnings from the Cancer Inequalities Programme especially in relation to the effectiveness of actions taken in terms of improving outcomes and experiences for patients.

2. Keep the Adults and Health Select Committee updated on the Surrey Heartlands NHS ICB Cancer Inequalities Programme and its impact on both the Health and Wellbeing Priority Areas and groups experiencing inequalities.

3. To improve accessibility, and to ensure that communication is effective and does not disenfranchise those who aren’t able to use technology in one way or another.

Meeting paused for a break at 11.08am

Meeting resumed at 11.45am