Analysed: Performance failings in Cambridge

Reputation

Not very long ago Cambridge University Hospitals Trust could claim to be among the best in the country - succeeding in its professed aim of being a “top five” trust.

It was renowned for its research role, led by a visionary chief executive, and was seen as a “good performer” providing excellent care. It was a leader among foundation trusts and was among the first to be authorised back in 2004.

But recently its performance has raised concerns.

Recent performance

Last month HSJ reported how it had been red rated for failing the 62-day cancer target for three quarters in a row (its performance for 2011-12 was 81.7 per cent) and had been called to Monitor’s office for discussions on whether it was in significant breach of its authorisation.

It is not the first time it has been red rated for cancer targets - it had a similar problem in the first quarter of 2011-12 but was restored to green in the second quarter. But from then it declined again and by the fourth quarter was rated amber-red.

But the 62-day target - which is proving troublesome to a lot of trusts - is not the only problem. The papers for the board of governors meeting in September showed that from April to July this year it only treated 85.5 per cent of admitted patients within 18 weeks and had also missed the 95 per cent four-hour A&E admission standard.

The trust has had eight never events in the last 12 months - several involving swabs left inside patients

NHS Cambridgeshire’s September board meeting heard that performance was only 93.4 per cent in the first four months of the financial year, although it had improved significantly in August and early September. Cancelled operations stood at 321 for the April to July period.

And the trust has had eight never events in the last 12 months - several involving swabs left inside patients during operations or procedures. On the CQC website, it is listed as needing improvements in three out of five areas. The last CQC visit - in April - led to a report highlighting issues around the use of surgical checklists.

So has the trust lost its mojo or is it just experiencing some of the pressures all trusts are facing at the moment - and reflecting the problems in the wider health economy it is working within?

The answer is not straightforward.

Delayed transfers of care

Many of the trust’s issues are related to delayed transfers of care and the impact that has on bed availability.

The trust says numbers of affected beds have been as high as 80 and can represent 12 or 13 per cent of the 600-700 beds available for adult patients. Beds occupied in this manner contribute to poor performance in a number of ways - when people can’t move out of A&E because there is nowhere to put them, when their operation is cancelled because there isn’t a bed, and when the trust breaches the 18-week standard because of this.

In bed number terms, the trust has one of the highest levels in the country. The latest figures from the Department of Health for August suggest there are several trusts in a worse position but Cambridge had 59 patients delayed at the point when the monthly snapshot was taken. 

Addressing delayed transfers

Addressing the issue of DTOCs is crucial to improving performance. The trust’s annual report for 2011-12 highlights the issue as a priority and outlines the impact it has on other aspects of performance and patient safety.

The work being done on this involves the PCT, county council, community trust and private providers as well as the acute trust.

The county council is recruiting additional staff to ensure that more patients can benefit from reablement

The focus is increasingly on reablement and the county council is recruiting additional staff to ensure that more patients can benefit from this approach. These staff provide social care but with a emphasis on helping the patient towards independence and receive training to deliver a programmed devised with occupational therapist and physiotherapist input. 

Cambridge believes that by offering this focused package as a patient is discharged, it can reduce the need for social care further down the line: patients who are encouraged to maximise their independence won’t need so much ongoing care.

But in the past this package has only been supplied to about a third of the people who could potentially benefit from it. To make it the default package for people coming out of hospital could mean the county council has to fund an additional 99 staff, although it hopes to make savings elsewhere as a consequence of increased independence. 

The discharge planning team previously reported to Cambridge Community Services but has been moved under the management of the acute trust to try to improve this process. The PCT has also bought additional inpatient community rehabilitation beds in the independent sector and is commissioning GPs to lead on multidisciplinary meetings for these patients.

The trust is also working with an independent provider to offer suitable patients follow-up care in their homes while remaining under the care of their consultant.  

Other actions include making it easier for GPs to phone the hospital for advice from a consultant geriatrician on managing patients who might be at risk of admission, helping them get early outpatient appointments, and support to get appropriate patients who have presented at A&E home without an admission.

Another issue affecting A&E waiting times has been major building work to the trust’s trauma centre. The most disruptive period of this work has now been completed - although some work continues - and performance has started to improve.

The trust met the 95 per cent four-hour standard for quarter two.

Cancer waits

But the immediate cause of the trust’s current problems with Monitor is its failure to treat a high enough percentage of cancer patients within 62 days of referral. It’s not alone in this: the 62-day target has caused issues for many trusts and tertiary centres. Like Cambridge, they argue they are often in a difficult situation with patients referred on from other hospitals when the clock has already been ticking for some time.

A new “reallocation” agreement - which deals with how breaches of the 62-day standard are dealt with - covering Cambridge University Hospitals and other NHS bodies in the area has now been agreed and the trust says that had that been in place it would have met the targets in every quarter.

However, it faces an additional challenge from an unexpected increase in the number of urological cancer referrals. For some particular cancers, referral rates have increased by 50 per cent. Why this should be the case is still being investigated - one factor could be increased recognition of the importance of early intervention - but it means the trust has struggled to treat those patients quickly. An additional surgeon is in place and additional operating theatre sessions arranged but the trust expects to have problems with this particular set of patients until three new surgeons are bedded in. This means it is not likely to reach the 62 days standard under quarter four.

PCT concern

But its commissioner - NHS Cambridgeshire - has expressed some doubts about how the trust is tackling some of these problems. In its July meeting the board heard that a “comprehensive proven set of actions” was not in place to tackle the referral to treatment time issues and that the timeline for getting back on track had slipped in some specialties.

At its September meeting the PCT cluster was told that it was now looking at penalties for some areas of poor performance and that an action plan had not delivered the planned reductions in backlog.

“It is unlikely that the agreed target recovery dates will be achieved,” a report suggested. Orthopaedics may only be compliant in January rather than October. The trust’s own board papers show that more than 1,000 patients have been waiting over 18 weeks: more than 300 of these are in orthopaedics.

The trust governors have also raised concerns including what the long term plan is for dealing with delayed transfers of care and how never events are handled.

But the trust is adamant that it is determined to tackle this problem and says it has already made changes. No patient harm resulted from the never events, it says, and it is working on standardising procedures to prevent them happening again. 

Finance

Cambridge University Hospitals has also struggled financially with a £2.5m deficit in 2011-12 - although this was less than predicted. Its income had increased by £29m in the year but it had been unable to cut costs by as much as planned.

That seems to have continued this year with the board hearing that £8m of £32m planned savings were red rated, unlikely to be achieved and were effectively being removed from its plans. Because of the short time left, there was no assurance possible that this would be filled by other savings and contingency funds would be used instead. Although it is not changing its forecast outcome of £4m surplus for 2012-13, it does mean that the recurrent savings locked in will be less than expected and this will increase the pressure on 2013-14. The trust does, however, expect to make £25m of recurrent savings this year.

Capital plans

Cambridge has ambitious plans for the future, including creating a ‘medical city’ with a new private hospital, hotel and conference centre. This has come under fire from shadow health secretary Andy Burnham but the trust has pressed ahead and has tendered for a private sector partner to form a joint venture company. The trust will contribute the land but no capital: it argues that proceeds from the joint venture will flow back into its NHS work.

The tender, however, suggests that this joint venture could be extended to include “other infrastructure and related services”. The trust expects to procure training and education services from its strategic partner but also sees itself as providing services back to the healthcare campus.

Longer term still, it would like to have its own children’s hospital; although there is broad support for this in the East of England, financing it is the key issue.

Competition

But while the Cambridgeshire health economy is relatively small, there are three trusts all battling for market share. Cambridgeshire has a population of just over 600,000 while the Peterborough area is under 200,000.

Both Peterborough and Stamford Hospitals Foundation Trust - battling with an enormous deficit - and Hinchingbrooke Health Care Trust - run by Circle - would like to do more lucrative elective work. Cambridge has ceded some to Hinchingbrooke in an attempt to reduce waiting times in orthopaedics but all three are likely to see elective work as crucial to their financial viability. Cambridge is best placed to attract this work - it is nicknamed the Death Star in some quarters for its ability to suck in work - but will need to tackle targets.

Governance

In governance terms, the trust has faced a period of enormous change with longstanding chair Dame Mary Archer announcing her intention to retire and chief executive Gareth Goodier deciding to leave for a role in Australia.

In governance terms, the trust has faced a period of enormous change

A new chair, Jane Ramsey, was announced in February and will take over within days.

Since Dr Goodier left in June the chief executive’s role has been filled by chief nurse and operating officer Karen Castille. Job advertisements for the permanent job appeared in the summer although it is not known whether the trust had tried to headhunt other candidates before that (Dr Goodier announced he was going in March). 

A report to the council of governors in September suggested an appointment to the chief executive’s job was imminent and “it is likely that a substantive chief executive will be in post before the end of the financial year”. That suggests that whoever is appointed will have a six month notice period to work out.

However, a month later no appointment has been announced and the line from the trust remains that a statement will be made soon. 

But if the trust has to wait until the end of the financial year for a new chief executive to be in place, it will have faced nine months without a permanent chief executive. It insists that this is not an issue and that it has a strong interim team.

The future

So what now for the trust? In November it should hear whether Monitor has found it in significant breach. But with evidence that it is tackling the issues with cancer waiting times and an improving situation in A&E it may well escape censure.

Its expansion programme is likely to continue - Addenbrooke’s Hospital is expected to pick up additional pathology work from the plans devised by NHS Midlands and East and likely to be approved within a few weeks. It has also become the regional trauma centre.

Its new chair will take up the post within days and the appointment of a new chief executive could then follow swiftly. But it is likely to be how the new arrangements for avoiding delayed transfers of care work out which determine whether Cambridge University Hospital’s reputation is fully restored. Director of operations Tom Bennett says: “The big risk is bed capacity.”