NHS Constitution Patient & Public Quarter 4 report 2011/12 1
Executive Summary The NHS Constitution was first published on 21 st January 2009. One of the primary aims of the Constitution is to set out clearly what patients, the public and staff can expect from the NHS and what the NHS expects from them in return. All NHS organisations are legally required to take account of the NHS Constitution in performing their NHS functions. The patient and public section of the Constitution cover seven key areas, these are: Access to services Quality of care and environment Nationally approved treatments, drugs and programmes Respect, consent and confidentiality Informed choice Involvement in your healthcare and in the NHS Complaints and redress There is a direct connect between the patient and public section of the NHS Constitution and the Operating Framework. Foundation Trusts are expected to demonstrate how they have taken account of the NHS Constitution within the Annual Governance Statement (previously Statement of Internal Control) included within their Annual Report. A revised version of the NHS Constitution was released by the Department of Health on 8 March 2012. This report is the final quarter report for 2011/12 to provide assurance to the Board that WWL NHSFT has continued to assess itself against the NHS Constitution during 2011/12. Quarterly reports are also monitored by the Engagement Committee. In 2012/13 the report will be revised to take account of the changes to the NHS Constitution in the next reporting year. Compliance with the pledges has been assessed for the Q4 period and evidence provided at Appendix 1, attached to this report. Recommendation The Trust Board is asked to note the content of this report to receive assurance that the Trust is fully compliant with the legal requirement to take account of the NHS Constitution in provision of its NHS services. Helen Hand Board Secretary 2
NHS CONSTITUTION PATIENTS AND PUBLIC 1. Access to Health Services Appendix 1 to provide convenient, easy access to services within the waiting times set out in the Handbook to the NHS Constitution; to make decisions in a clear and transparent way, so that patients and the public can understand how services are planned and delivered to make the transition as smooth as possible when you are referred between services, and to include you in relevant discussions. Rights Update RAG /Non receive NHS services free of charge, apart from certain limited exceptions sanctioned by Parliament. access NHS services. You will not be refused access on unreasonable grounds. expect your local NHS to assess the health requirements of the local community and to commission and put in place the services to meet those needs as considered necessary., in certain circumstances, to go to other European Economic Area countries or Switzerland for treatment which would be available to you through your NHS commissioner. not to be unlawfully discriminated against in the provision of NHS services including on grounds of gender, race, religion or belief, sexual orientation, disability (including learning disability or mental illness) or age. 3 PCT commissioned services are provided free at the point of delivery by WWL with the exception of those sanctioned by Parliament. In addition some services now require prior approval via the PCT. Access to services is available using a range of options including Choose & Book, Direct Access Clinics, A&E, WIC Failure of 18 week target for some services during this quarter PCT Commissioning plans in place to commission services from WWL QIPP Board established to forward plan future of locally provided services 18 weeks performance reported to Trust Board Council of Governors engaged in service planning Monitor 3 year plan publically available Healthy Hospital Strategy approved by Trust Board Unscheduled Care Focus Groups held x 2 with patients/public to redesign patient pathway Engagement of membership and Governors in the S&SS redesign. Ongoing EBD surveys PCT Commissioner responsibility N/A N/A WWLFT Single Equality Scheme in place. Equality & Diversity Steering Group in place to monitor Trust s performance Equality & Diversity procurement plans ongoing Equality impact assessment on policies/plans ongoing E&D Plan approved by the Board Nov.2011 Equality Objectives report sent to Board March 2012 in most areas
2. Quality of Care and Environment to ensure that services are provided in a clean and safe environment that is fit for purpose, based on national best practice (pledge); to continuous improvement in the quality of services you receive, identifying and sharing best practice in quality of care and treatments Rights Update RAG /Non be treated with a CQC registration maintained without conditions professional standard NHSLA standard level 2 achieved of care, by Monitor quarterly reporting in appropriately qualified accordance with terms of and experienced staff, authorisation in a properly approved SBAR and NPSA alerts regarding or registered patient safety issues. organisation that Adherence to NICE guidance meets required levels Falls project won HSJ award of safety and quality 6 Wards registered to be harm free wards Positive CQC visit 27.6.11 Maintained CQC Registration without conditions during the expect NHS organisations to monitor and make efforts to improve the quality of healthcare they commission or provide quarter Staff IMPACT training Divisional Quality Accounts established across the Trust with Quality indicators approved by Audit committee Internal clinical and non clinical audits are undertaken against standards PEAT audits demonstrate clean and safe environments. Real Time Patient Experience Survey, Exit Survey Quality and Safety Matrons now corporate Ward to board reports includes cleanliness. National Survey Programme in top 20% of Trusts Time to Care Project Patient Experience Task Force led by CEO Engagement with AquA projects Rapid Spread initiative Quality is a core Corporate Objective Energising for Excellence Initiative Harm Free Wards initiative 4
3. Nationally approved treatments, drugs and programmes The NHS commits to provide screening programmes as recommended by the UK National Screening Committee Rights Update RAG /Non drugs and treatments that have been recommended by NICE for use in the NHS, if your doctor says they are clinically appropriate for you. Medicines Management Policy NICE guidance adherence Antibiotic prescribing policy Medicines Safety Committee has Governor representative Board presentation on Prescribing Jan 2011 expect local decisions on funding of other drugs and treatments to be made rationally following a proper consideration of the evidence. If the local NHS decides not to fund a drug or treatment you and your doctor feel would be right for you, they will explain that decision to you. Medicines Management Policy NICE guidance adherence Antibiotic prescribing policy Medicines Safety Committee has Governor representative Board presentation on Prescribing Jan 2011 receive the vaccinations that the Joint Committee on Vaccination and Immunisation recommends that you should receive under an NHS-provided national immunisation programme PCT responsibility N/A N/A 5
4. Respect, Consent and Confidentiality To share with you any letters sent between clinicians about your care Rights Update RAG /Non to be treated with dignity and respect, in accordance with your human rights. to accept or refuse treatment that is offered to you, and not to physical examination or treatment unless you have given valid consent. If you do not have the capacity to do so, consent must be obtained from a person legally able to act on your behalf, or the treatment must be in your best interests. to be given information about your proposed treatment in advance, including any significant risks 6 Code of Confidentiality, Dignity and Respect Policies in place and adhered to. Clinical care policies, procedures and guidance are in place. These are subject to impact assessments. Compliance with mixed sex accommodation. Mix sex accommodation audits undertaken Mixed Sex Occurrence Policy Chaperone Policy adhered to. Copying Letters to patients Policy Interpreter service available. Patients can apply under the data protection to access their health records. Information Governance Toolkit compliance monitored via Audit Committee Code of Conduct in place Good scores for patient letters in 2011 survey A range of clinical care policies, procedures and guidance are in place. These are subject to impact assessments. with mixed sex accommodation. Mixed Sex Occurrence Policy Chaperone Policy adhered to. Treatments will be explained to patients as far as possible and repeated if necessary. Consent audits undertaken Learning from complaints monitoring Vulnerable child/adults/safeguarding policies in place LD Hospital visit programme Information Leaflets NHSLA compliant Pre Op assessment Specialist Nurse support Learning from complaints monitoring NHSLA Level 2 achieved Complaint
and any alternative treatments which may be available, and the risks involved in doing nothing. to privacy and confidentiality and to expect the NHS to keep your confidential information safe and secure. of access to your own health records. These will always be used to manage your treatment in your best interest. 5. Informed Choice CNST Level 1 (maternity) achieved Working towards NHSLA Level 3 assessment Protecting your data information Information Governance Toolkit monitoring via Audit Committee SIRO position held on Trust Board Caldicott Guardian on Trust Board Information Governance Committee monitoring role Informatiion Governance Level 2 achieved for all 22 essential standards at last assessment Access to Health Records information Patient Relations support PALS service relaunched Patient Choice website feedback To inform you of healthcare services available to you, locally and nationally To offer you easily accessible, reliable and relevant information to enable you to participate fully in your own healthcare decisions and to support you in making choices. This will include information on the quality of clinical services where there is robust and accurate information available Rights Update RAG /Non PCT responsibility n/a to choose your GP practice, and to be accepted by that practice unless there are reasonable grounds to refuse, in which case you will be informed of those reasons to express a preference for using a particular doctor within your GP practice and for the practice to try to comply. PCT responsibility n/a 7
to make choices about your NHS care and to information to support these choices. The options available to you will develop over time and depend on your individual needs. Patient Information Leaflets NHSLA Level 2 compliance achieved Leaflets are also available in alternative formats such as large print Braille alternative languages and audio. Leaflets are available for download on the internet/intranet Information on National ratings Choices Website CQC ratings Monitor Compliance Framework Consultant Profiles on WWL internet Patient Opinion Project launched 6. Involvement in your healthcare and NHS to provide you with the information you need to influence and scrutinise the planning and delivery of NHS services to work in partnership with you, your family, carers and representatives. Rights Update RAG /Non be involved in discussions and decisions about your healthcare, and to be given information to enable you to do this be involved, directly or through representatives, in the planning 8 Decisions in clinical care monitored by national survey programme Involvement in decision monitored in RTPE survey Information on how to become involved in the design and delivery of services is distributed via the Membership and Engagement Department. Membership panels used to comment on patient information Membership panels used to comment on Trust plans and performance Monitoring through national and internal surveys Focus Groups held on Service & Site Strategy Workshop on unscheduled care held x 2 to redraw gold standard pathway Patient Opinion now live A series of membership events have taken place in the Community. These events are designed to inform the community of our services and to inform members of the public
of healthcare services, the development and consideration of proposals for changes in the way those services are provided, and in decisions to be made affecting the operation of those services how they can become a member of the Trust and help to influence and design our services. The Membership Strategy has been reviewed and approved by the COG Membership Group. The new strategy s aim is to increase engagement opportunities. COG involvement in service planning Membership panels used to provide service planning feedback Trust consultations on significant changes will be undertaken in full compliance of Section 242 of The Act Survey of patients and trust members undertaken as part of Service and Site Strategy listening exercise Focus groups held Close liaison with PCT/OSC in service change Engagement with LINK in service change Engagement with GP Commissioners in service change Patient Focus group x 2 on urgent care pathway redesign Governor and patient involved in S&SS redesign teams Successful 21 st Century Cancer Services event 7. Complaint and redress To ensure you are treated with courtesy and you receive appropriate support throughout the handling of a complaint; and the fact that you have complained will not adversely affect your future treatment when mistakes happen, to acknowledge them, apologise, explain what went wrong and put things right quickly and effectively to ensure that the organisation learns lessons from complaints and claims and uses these to improve NHS services Rights Update RAG /Non have any complaint Patient Relations Team support complaints you make about NHS services dealt with Complaints monitoring reported at Trust Board 9
efficiently and to have it properly investigated know the outcome of any investigation into your complaint take your complaint to the independent Health Service Ombudsman, if you are not satisfied with the way your complaint has been dealt with by the NHS. make a claim for judicial review if you think you have been directly affected by an unlawful act or decision of an NHS body. compensation where you have been harmed by negligent treatment. Complaints reported within the Annual Report Internal target for response to complaints set Complaints policy revised to embed system at Divisional level Medical Director sees all complaints Complaints response devolved to Divisions Patient opinion launched Complaints letter signed off by the CEO Meetings facilitated by Patient Relations Team to discuss individual complaints Complaints reviewed by Medical Director Red RAG rated complaints and SUI monitoring meeting established Survey of complainant satisfaction pilot Complaints policy in place in accordance with legislation requirements Complaints policy in place in accordance with legislation requirements Legal Services Department in place for compensation claims Legal Services annual report approved by Trust Board Nov 2011 Complaint 10