Cumbria Health Scrutiny Committee

Thursday 16th October 2014

Background Information

Healthwatch Cumbria (HWC) is in place to deliver the statutory HW functions set out in the Health and Social Care Act 2012 on behalf of Cumbria County Council. It has now been operational for 18 months and this report provides information on how it has risen to the vast challenge to be the health and social care champion for the people of Cumbria. The role requires HWC:

• To be both strategic and operational• To use a wide range of relationships and networks effectively• To create, raise awareness about, and put in place systems, processes and

mechanisms of engagement, • To develop an effective and influential evidence base, and signposting

system, To listen to the experiences of the public of health and social care services

and analyse and collate trends using these to inform its work programme • To carry out enter and view visits within the framework of the national

regulations • To respond to a wide variety of requests for involvement and/or activity

HWC is able to provide additional information and evidence to assist the Cumbria Health Scrutiny Committee’s work programme.

Focus for Healthwatch Cumbria report for 16 October 2014.

In line with the agenda for its meeting on 16 October 2014, this report provides Cumbria Health Scrutiny Committee with a summary of HWC knowledge in relation to people’s experiences of;

Mental Health Services Community Hospital Meals Cancer Services

The report also includes a brief update on other current HWC operational and engagement activity for members of the committee.

Mental Health services

Cumbria Mental Health Commissioning Strategy for Adults 2014-17 Survey Following a request from CCG one of our partner projects co-hosted by People First, The Best Life Wellbeing Network, carried out an extensive survey of mental health service users, their careers and families and of providers to inform the development of the emerging Mental Health Mental Health Commissioning Strategy for Adults.

The survey was designed to explore;

Current experiences of mental health services Priority areas for improvement Ideas and suggestions for improvement

An extract from our report which was delivered to CCG is included here and a full copy of the report, the survey and the summary presentation are appended to this report and are also available on the People First website.

Response Rate Total respondents 262 118 online 144 paper

N.B. Questions 1b to 3e were presented so as to allow the respondent to choose multiple options as they wished (please see survey attached as appendix 2). Therefore percentages reflect this and will not total 100% when added together.

Question No. Responses

Response Rate

1) Have you experienced any obstacles in accessing mental health services?

255 97%

2) Which one service do you think should be a priority?

250 95%

3.) Which areas would you like to see an improvement at the following services?

A) GP Services 241 92%B) First Step 199 76%C) CMHT 223 85%D) Crisis Teams 214 82%E) Inpatient Services 200 76%4.) What do you think is working well in the mental health services you have experienced?

170 65%

5.) Do you have any ideas about improvements that could be made to mental health services in Cumbria?

203 77%

Emerging Trends

Perceived Access to Mental Health Services 64.7% of those responding had experienced obstacles accessing mental

health serviceso Of those respondents the most frequently reported obstacles were

accessibility (31%) and lack of information about mental health services (27.1%).

Prioritised Service for Improvement 95% of respondents prioritised one service they thought should be improved.

o Community Mental Health Teams were the most frequently prioritised service by respondents, with 36% of respondents prioritising them for improvement.

o The least prioritised service was Inpatient Services, with 8% prioritising it for improvement.

GP Services 92% of respondents indicated what improvements they would like to see at

GP Services.o 61.4% would like to see improved mental health awareness from staff.o 52.3% would like to see improved appointment availability.

First Step Services 76% of respondents indicated what improvements they would like to see at

First Step Services.o 59.3% indicated that they would like to see improved waiting and

referral times.o 55.3% indicated they would like to see an improved range of therapies

and treatments.

Community Mental Health Teams 85% of respondents indicated what improvements they would like to see in

Community Mental Health Teams.o 62.3% indicated they would like to see improved consistency of

service.o 57% indicated they would like to see improved waiting and referral

times, 52% indicated they would like to see improved staffing levels and availability,

Crisis Teams 82% of respondents indicated what improvements they would like to see in

Crisis Teams.o 56.1% indicated they would like to see improved staffing levels and

availability.o 55.6% indicated they would like to see improved response times and

47.2% would like to see improved consistency of service.

Inpatient Services 76% of respondents indicated what improvements they would like to see at

Inpatient Services.o 60.5% indicated they would like to see improved bed numbers.o 52.5% would like to see improved availability of structured activity.

General Trends Across all services there was a general trend of respondents indicating they

would like to see improved communication at services. Few respondents indicated they would like to see improved confidentiality. It

was the least frequently chosen area of improvement in all five services listed.

Confidential appendix to be inserted here which is to be tabled at the meeting.

In summary the key themes emerging in relation to the experience of people of mental health services in Cumbria are:

Concern over CAHMS services for those with autisms, particularly delays on diagnosis and a perceived lack of knowledge from staff for young people;

Involvement of carers in appointments and decision making; Problems with out of hours access to emergency support systems and staffing

of crisis team; Issues with the placement of patients in accommodation outside of the

County, the impact upon patient and carers, and unavailability of accommodation within the County;

Issues with care co-ordination for patients outside of the County due to care co-ordinator not attending meetings;

Perceived issues with diagnosis and care for service users with acute MH conditions from CMHT;

Access to emergency GP appointments difficult for those with MH illnesses; Negative experience of at least one ex-service person in getting treatment

for Bi-polar and PTSC

At the recent HW England annual conference we learned that this issue is not unique to Cumbria and that there are serious concerns about CAMHS and Crisis Mental Health nationally.

Whilst HWC would not wish to duplicate what has already been carried out, the level of concern and numbers of issues reported has escalated the importance of this issue in the HWC work plan. We will begin a comprehensive review of research available on mental health services and patient experience in November 2014. We aim to report findings in February 2015.

Community Hospital Meals

HWC was originally approached in May by the Maryport League of Friends to look into the issues surrounding hospital catering, in particular in Community Hospitals. There was concern that there was going to be a switch from in-house prepared meals to bought- in microwaved meals.

HWC carried out public engagement sessions in Keswick and Millom in April and recorded positive and negative feedback from those people that engagement officers spoke to in relation to hospital catering.

Concerns that nutrition is key to rehabilitation and recovery for inpatients, but not deemed to be taken seriously by the service providers;

• Service users very positive about the quality of inpatient meals in Keswick, Millom and Cockermouth hospitals.

The public also commented on broader aspects of hospital catering as follows;

“Last week’s article re: microwave meals at local hospitals was appalling, patients need nutritious food.”

“Food in Cumberland Infirmary Carlisle is not consistent and ranges from very poor to barely adequate”

“In Keswick we have had superb food & services. Concerned that it will stop”

“Home cooked food is getting people better, meals are great but not microwaved, Cumberland Infirmary Carlisle food is not good”

“Food at Cumberland Infirmary Carlisle is unpalatable – patients are being brought ready meals, I didn’t eat for 2 days”

“Keswick Hospital, microwaved meals for my 92yr old mother doesn’t work. She only eats half of it and is far better when she eats home cooked food. Why use ready meals when there’s a kitchen and skilled staff to cook?”

Our evidence suggests that although there is some support for the quality of some meals, there remain a number of concerns about nutrition and also about the quality and sustainability of the existing services in both in community and larger hospitals.

Our latest information is the Cumbria Partnership NHS Foundation trust has deferred a decision on the move to replace in-house preparation with microwavable meals in community hospitals. Our initial research would suggest that there would be merit in exploring further the relationship between quality, nutritious meals prepared on site and the continued and enhanced wellbeing of patients.

Cancer Services Review

HWC has repeatedly received concerns at HWC district meetings, during engagement sessions and at roadshows about the varying levels of service provided by all cancer services in Cumbria. We are also aware of complaints being brought against services through the Independent Advocacy Service for NHS Complaints, which is provided by our parent organisation People First.

The nature of complaints and concerns is varied and includes:

• Failure to diagnose• Late diagnosis• Chemotherapy being unavailable• Radiotherapy being unavailable locally• Patient records being mislaid causing delays in treatment• Poor coordination of services between Trusts and community services

In order to explore these concerns in more detail HWC has set up a Task and Finish Group specifically focused on Cancer Services. HWC has designed and widely circulated a survey to capture and analyse current experiences.

We have received support from many 3rd sector support agencies with the preparation of the survey and its circulation. As well as the survey data, we will increase our evidence base by carrying out visits to Trust clinics over the next 3 weeks. The evidence presented will be analysed and reports drafted by the 31st October 2014. We will share our findings with Cumbria Health Scrutiny Committee and with all appropriate Services, Commissioners, and Regulators in order to influence improvements.

Car Parking Task and Finish group

Car parking at West Cumberland Infirmary and Cumberland Infirmary Carlisle has been an ongoing concern for several years. The HWC Task and Finish group continues to investigate the issues surrounding parking and to identify possible solutions. HWC has met with NCUHT on 2 occasions and presented concerns raised by the public and the Task ad Finish group. These issues were discussed with the Trust’s CEO and Director of Estates and HWC is aware of some progress being made around possible identification of land for parking. A parking strategy was presented to the Trust Board recently and we await an update from the Trust. HWC is the process of designing and carrying out a further survey to explore the impact of parking constraints on the patients and other members of the public.

Complaints Task and Finish group

HWC has now embarked on phases 2 and 3 of this work which will focus on complainants’ experience of complaints handling and the services approach to embedding and sharing learning and improvements within their respective organisations.

Best Life MHS Complaints Advocacy

Members of Cumbria Health Scrutiny Committee are already aware of ability of HWC to draw from the rich statistical information provided by the Best Life Independent NHS Complaints Advocacy service. This service supports anyone over the age of 16, living in Cumbria, to raise concerns and complaints about their care or treatment under the NHS. This statutory service is run by People First Independent Advocacy and is funded by Cumbria County Council (CCC) as part of its statutory requirements.

The data below is taken from the quarter 1, year 2 report and covers the period from 1 April to 30 June 2014.

Best Life Independent NHS Complaints Advocacy has received 71 new referrals within this reporting period, reporting a continued rise of 24% in the number of NHS complaints handled this quarter.

Despite the increase in the number of issues handled, we have also seen a corresponding increase in the number of issues resolved highlighting the increasingly effective and efficient working practice of the service.

Of the complaints handled by the service we have identified trends including an increase in complaints handling, mental health and medication related issues. However we have also seen a decrease in caseload involving inpatient care.

Issues

This section details the full range of customer’s NHS complaint issues including the resolution level set by Customers at the point of case closure.

Chart 1 details the resolution level of complaints over the last three reporting periods.

Chart 1

Since the previous quarter the number of issues we are working on has increased by 24%. Despite an increased work load, compared to last quarter, the proportion of issues which are either fully resolved or part resolved has increased by 4% as evidenced by table 2 below:

The table below shows a breakdown of issues across Cumbria during this reporting period. The table is broken down into resolution level for cases closed and on-going if the referral is still open (276 issues in total).

Table 1

Issue Resolved Part Resolved

Not Resolved

Ongoing Total

Access to Services: Mental Health

0 0 0 1 1

Complaints: Other 0 0 0 1 1Access/Remaining on GP Lists 0 0 0 1 1Admissions/ Discharge/ Transfer arrangements

0 1 0 6 7

Appointments – Delays/ Cancellations

4 5 1 9 19

Attitude of Staff 8 4 2 11 25Cleanliness/ Hygiene 0 0 0 1 1Commissioning of Services 1 1 0 1 3Communication Issues 6 3 1 12 22Complaints Handling 5 3 1 7 16Consent to Treatment 0 0 0 1 1Dental Treatment 2 1 1 6 10Emergency Care 1 1 0 1 3Failure to Diagnose 8 3 2 32 45GP 0 0 0 1 1GP conduct 0 0 0 2 2In patient care 9 5 1 18 33Medication related issues 5 3 1 12 21Mental Health 2 2 0 10 14non referral or unwillingness to refer

1 0 0 3 4

Nursing Care 0 0 1 3 4Patient Privacy and Dignity 0 0 0 2 2Patient Property/ Expenses 0 0 0 1 1Patient Status/ Discrimination 1 0 0 0 1Personal Records 0 0 1 4 5Surgery Issues 5 3 0 9 17Transport (ambulance etc) 0 0 0 1 1Treatment by GP 2 0 0 2 4Treatment in hospital 2 1 0 5 8Waiting Times 2 0 0 1 3Total 64 36 12 164 276

Failure to Diagnose, In-patient Care and Attitude of Staff continue to be the most common complaint issues. The majority of these relate to Hospital Trusts and often entail prolonged investigations at the local resolution stage.

The following table highlights trends observed over the last two quarters. Where these can be attributed to specific NHS providers, these will be discussed in more detail in the Issues by Provider section.

Table 4

Jan-Mar 2014

Apr-Jun 2014

% change

Complaints Handling 11 16 45%Dental Treatment 6 10 67%In patient care 37 33 -11%Medication related issues 14 21 50%Mental Health 6 14 133%Personal Records 2 5 150%Treatment in hospital 0 8 800%

During this quarter we have seen a 45% rise in issues relating to complaints handling, the majority of which relate to the Morecambe Bay University Hospitals Trust. This information has been fed to Healthwatch and is being utilised in their Complaints Handling Task and Finish Group. This is discussed further in the report.

The majority of the 50% increase in medication related issues can be attributed to HMP Haverigg where we have continued to see a rise in referrals this quarter.

The 133% increase in complaint issues relating to mental health could be partly attributed to the recent work of the Best Life Wellbeing Network (BLWN) following a request from the Cumbria Clinical Commissioning Group (CCG) to the BLWN to conduct a survey on its behalf to identify how Mental Health Services are performing and how they could be improved. And is part of the consultation process to develop the Mental Health and Emotional Wellbeing Strategy. Furthermore, there has been increased negative coverage in the media relating to mental health services in Cumbria.

The rise in ‘Treatment in Hospital’ this quarter can be attributed to North Cumbria University Hospitals Trust which is evidenced in Chart 6.

Issues by Provider

This section identifies the main issues in each NHS provider during this reporting period.

Cumbria Partnership NHS Foundation Trust

The following chart details issues relating to Cumbria Partnership Foundation Trust (CPFT) during the last two reporting periods.

Chart 4

We are reporting a 9% rise in issues relating to CPFT this quarter. Including a 100% rise in mental health service issues. This is not surprising due to the fact that CPFT predominantly deliver mental health services however this is still concerning when improvement is a central theme. During this reporting period we have worked on a number of cases where customers have raised complaints about general poor service, communication and waiting times relating to the Community Mental Health Teams and the Crisis Teams.

A high proportion of these complaints are ongoing complaints from previous quarters due to the challenges customers face because of their mental health need. We have received feedback from customers that they find it extremely difficult to raise a complaint about people who have power and control over what happens to their treatment and medication. These customers report that they find the NHS complaints advocacy service particularly empowering. Other complaint cases include access to the Crisis Team and communication between the Crisis Team and the Community Mental Health Teams.

The key issues have been provided to Healthwatch and the Best Life Wellbeing Network. These services have the benefit of mutual cooperation and intelligence sharing, whilst also having different routes to raise issues with decision makers which strengthens patient voice.

University Hospitals of Morecambe Bay NHS Foundation Trust

The following chart details the issues for Morecambe Bay University Hospitals Trust (MBUHT) for this quarter and the previous quarter.

Chart 5

During this reporting period there has been a 26% increase in complaints issues relating to MBUHT, with increases in appointment delays, poor complaints handling, dental treatment and understanding of customer’s mental health issues.

We have experienced 125% increase in customers raising further complaints against the Trust in relation to how their complaint is being handled. Customers have reported experiencing lack of responses to correspondence, inability to meet time frames and deliberately ignoring customer contact. This does not fall within the spirit of the NHS Complaints regulations. Best Life Independent NHS Complaints Advocacy has raised this directly to Healthwatch which is currently convening an NHS Complaints Task and Finish Group. Healthwatch has completed phase one of this work and has invited us to be involved further in the next stage by identifying cases that could be tracked to see where the issues raised has had an impact on improvements and where customers are aware of the way their experience has driven that improvement.

North Cumbria University Hospitals NHS Trust

The following chart details issues relating to North Cumbria University Hospitals Trust (NCUHT) during the last two reporting periods.

Chart 6

During this reporting period we have experienced a 21% increase in issues relating to NCUHT.

A high proportion of this increase relates to treatment in hospital. In the most serious of these cases the customer believes the course of treatment, delay in treatment or lack of treatment has resulted in the death of a relative.

During this reporting period there has been a 40% increase in complaints relating to the attitude of staff. Customers have reported:

feeling “dismissed” “not taken seriously” in terms of symptoms “receiving no customer service”

A small number of customers told us they had tried to address their complaint whilst an in-patient however had not received an adequate response.

During this reporting period we worked with a client with a history of mental health issues, who was instructed by a specialist doctor to present to the Accident and Emergency Department should they experience specific symptoms relating to a physical illness. When the customer arrived at Accident and Emergency, the health staff tried to treat the person for the mental health issues they presented with instead of the physical problems. This resulted in the customer being removed from the hospital with Police involvement without the medical treatment they required.

A number of cases we are currently handling have been ongoing for a number of years and relate to in-patient care and failure to diagnose which resulted in the death of a patient. The initial NHS complaint was made within the time frame set out in the NHS regulations. However the investigation carried out by the Trust was deemed inadequate by our customer who has since raised an application to the Ombudsman with our support. In some cases the customer has been provided with answers to questions raised in the complaint which contradict recordings in the patient’s medical notes.

Dentists in Cumbria

The following chart details issues relating to dentists in Cumbria during the last two reporting periods.

Chart 7

We are reporting a 20% decrease in issues related to Dentists in Cumbria that were raised to the service. This decrease relates to a number of cases closed during the previous reporting period, the majority of which were closed at the local resolution level.

We have worked on one case relating to serious side effects of dental treatment where the customer suffered a stroke. We have provided the customer with information on approved medical negligence solicitors, at their request, after the dentist completed their investigation into the complaint. The outcome of which was not to uphold the complaint.

We have supported one customer who raised a complaint relating to the attitude of staff. This was resolved at the local resolution stage during the previous quarter after a prolonged period of time. We have since supported the customer to make an application to the Ombudsman who has agreed to investigate the way in which the complaint was handled.

GPs in Cumbria

The following chart details issues relating to GPs in Cumbria during the last two reporting periods.

Chart 8

During this reporting period there has been a 25% increase in NHS complaints issues relating to GPs in Cumbria. A number of customers have raised multiple issues relating to access to mental health services and medication related issues. In one case, a customer feels like they are being denied the appropriate medication due to the GP being unwilling to refer to the appropriate service.

We have experienced a small number of cases relating to accessing referrals to specialist treatment for Chronic Fatigue Syndrome (ME). Customers report services in Cumbria as restricted to Keswick or Newcastle. Customers tell us that the symptoms of ME often make travelling long distances challenging. One customer is raising a complaint with regards to waiting times for the appointment after a delay in the referral to the service caused by the GP.

One customer, whose complaint was resolved at local resolution, has reported to us that, since making a complaint, the attitude of the staff at her GP surgery has greatly improved and she feels like she is being listened to.

Customer complaints relating to Failure to Diagnose within GP surgeries has increased by 44%. In three cases, the issue relates to Oncology where the customers believe the GPs have failed to recognise and diagnose cancer symptoms of relatives which resulted in the deaths of three patients. These cases are not linked. This is contributing to the evidence base which is supporting Healthwatch to explore issues relating to cancer services in its forth coming Oncology enter and view project.

HM Prison Haverigg

The following chart details issues relating to HMP Haverigg during the last two reporting periods.

Chart 9

We are reporting a 36% increase in complaints issues which may be due to ‘word of mouth’ within the prison. The majority of which can be attributed to an increase in medication related issues. This issue has been the most common NHS complaints issue within the Prison.

Our service has developed a protocol with regards to working alongside customers in Haverigg to address some of the challenges we face with regards to communication and access. For example regularly liaising with customers with regards to probation and changes in sentence lengths, which can impact on the continued relevance of the complaint.

Additional HWC Engagement ActivityMembers of Cumbria Health Scrutiny Committee will also be interested to know about the ongoing engagement activity currently being undertaken by HWC.

HWC has made great progress in distributing information about, and providing access to, its services for everyone in a wide variety of ways, including outside market stalls, through our offices, at Healthwatch District meetings, electronically through the website, through a wide variety of promotional material available in different settings, with regular newsletters and by presentations and talks. Specifically:

• Approximately 5,000 people have engaged with HWC in a variety of ways to suit their needs.

• We have received numerous direct contacts through the info@healthwatchcumbria email address and helpline. Many of these customers who contacted us wished to raise a complaint. We referred these to the NHS Complaints Advocacy service, which is managed by our parent organisation, People First Independent Advocacy. This alignment is both effective and efficient for customers as they are able to receive the support they require through a quick transfer to another member of People First staff.

• We identified 600 key stakeholders with which to make contact and promote our services. A target was set to cover 200 providers/stakeholders per year. We met this target in year one, and are currently on target for year two, which means that more people can access information in their local services;

• A short British Sign Language signed HW film for people with hearing loss/deafness or are deaf has been uploaded onto the HWC website and has been well received by Cumbria Deaf Vision.

• HWC presentations are currently being delivered in each of the Cumbria Deaf Vision centres – Whitehaven, Carlisle, Barrow and Kendal.

• HWC information sheets in a variety of languages (informed by the Cumbria Observatory) have been uploaded onto the HWC website.

• E-bulletins are sent out fortnightly and subscriber numbers have increased steadily over the past 12 months, we currently have approximately 700 subscribers.

• HWC has delivered 13 engagement roadshows in towns across North Cumbria as part of the Together for a Healthier Future consultation programme. Feedback gathered from these events has been used to inform the CCG/Cumbria Health & Care Alliance 5-year plan.

• HWC has taken part in CQC listening events and directly engaged with attendees (public)

• HWC provided a drop-in session at LGBT Headquarters in Carlisle.

• HWC provided drop-in information sessions as part of Learning Disabled week – 16th June.

• HWC participated in Cumbria Pride 2014, in Carlisle and engaged with the LGBT community.

• 10 public engagement roadshows in the South Cumbria area

HWC has also received information about experiences through its info@healthwatchcumbria mail box, via its Helpline and through other individual conversations with members of the public.

The data from our engagement activity is collated and analysed so that it can inform future policy shaping and planning, highlight real issues of concern and also provide evidence to help inform improvements to service delivery.

Sarah Allison Health and Wellbeing Manager30 September 2014