Wednesday, June 27, 2012

BHRUT not going bust

Whoops, thanks to Imogen at BHRUT for explaining I should have read Guardian piece more carefully.
BHRUT is not going bust. Apologies if I confused anyone.

Is BHRUT bust? & BBC report

Guardian is running a new story at link saying

"The Barking trust has to find nearly £50m this year on its PFI deal agreed in January 2004, but is one of seven, including South London NHS trust now being allowed to go bust,"

I have phoned BHRUT about this and hope a statement by BHRUT will be issued soon.

A BBC piece on the CQC report is at

it says

"The Care Quality Commission (CQC) said Barking, Havering and Redbridge University NHS Trust had only achieved 27 of its 81 previous recommendations"

Special Measures for BHRUT?

The Guardian reports today at   that BHRUT "Second health trust is put on financial danger list" and goes on to say the Trust "could face special measures designed to rescue those in trouble"

This begs the question of what the special measures are, let's hope some more information comes out soon.

CQC report

The CQC report on KGH and Queens has been published, a bit that stands out for me is at page 8 which I copy below. The highlighting is mine.

Emergency care remains the area of greatest concern to CQC. Demand on
services is enormous and our original investigation and inspections since have
found this service is consistently failing to meet essential standards.
A combination of demand, problems with staffing, challenges in streaming
patients properly, and blockages elsewhere in the hospital mean the emergency
department at Queen’s in particular is struggling to deliver acceptable care.
Patients often face significant delays in admission, treatment and discharge.
The lack of available beds across the hospital causes a backlog that has an
impact on people arriving in A&E. The hospital continues to struggle to recruit
middle grade doctors and there is reliance on doctors from locum agencies.
This reduces the level of senior medical cover in the department, meaning it can
be difficult to find people qualified to make decisions about treatment, which
leads to delays in people being given access to the right care.
This level of concern about emergency care is corroborated by a range of
external sources, ranging from information from patients and other stakeholders,
through to performance data and other regulatory sources. A major programme
of work is underway at the Trust, supported by external partners, to try to
address this. More detail on this programme - and on our recent inspection
findings - is in section 3.ENDS

NHS management should respond to this report by abandoning KGH A&E and maternity closure plans, but I am not sure they will do this, so the campaign needs to keep going. Most organisations work on a first in first out basis when it comes to redundancy, I guess the NHS is no different.
The closure plans means an incredible 25% reduction in medical staff per page 123 of the NHS decision making business case by 2015. Is it any wonder BHRUT is struggling to recruit permanent staff when it is the record as saying that 1 in 4 are to be sacked by 2014?

At page 7 of the report the CQC say
The North East London and City cluster has taken on formal responsibility for
implementation of this maternity plan, which will see decisions taken across the
cluster to improve access to safe maternity care. This has already seen plans
implemented (spring 2012) to move around 20 bookings a week from the Trust
to Barts Healthcare, taking advantage of capacity elsewhere in the cluster
(particularly Newham Hospital). These bookings will translate into births from

So it seems large numbers of women will be going to Newham, not an easy journey and KGH maternity is to close, how can this be an improvement in the sevice?

I am encouraging KGH activists to ask questions about KGH at full council on 19th July. I will not looking to put down a question which is critical of the  Redbridge administration. My first draft question is;

Does the Leader of the Council agree with Mike Gapes and Lee Scott MP that the London Ambulance Service should publish a risk assessment on whether the proposed closure of King George A&E in the future will have an adverse impact on Redbridge residents?

I asked the LAS about this some time ago and was ignored, if full council is with Mike and Lee on this, hopefully LAS will provide a response. Good questions on the 19th and a well attended meeting on the 20th will help keep the campaign going. If you have any ideas for questions on the 19th please let me know.
More than ever, I am convinced that Lee Scott's claim that people will die if these closure plans go through is correct and if you can help the campaign in any way it will be much appreciated.

Monday, June 25, 2012

A Board Cull and “Creating Barts Health”

Neil Zammett writes
This week I want to cover two very different issues: the news of management changes at BHRUT and a session on ‘Values’ at Barts Health I attended on behalf of Health Scrutiny.
The Cull
Like most people I was very surprised to receive a letter from Averil Dongworth the Chief Executive of BHRUT announcing management changes.  It was not so much the news of changes but the very vague way in which the news was expressed. After a long follow in recording recent management developments presented very positively there was a general statement about members “leaving” the executive team.’
A few days later the Romford Recorder ran a front page article about the “Board Cull”; five executive board members leaving the Trust with a ringing endorsement of the action by a local MP.  In contrast the Ilford Recorder ran a very different story saying that the five executive directors had asked Mrs Dongworth “to make some difficult decisions” and that there was “A lot of shock and upset in the hospital”.
The problem is that we have no specific statement about what has happened which has created a situation where speculation is inevitable.  There is nothing yet on the BHRUT website to confirm or deny the press stories.
The way that events are unfolding does no service to transparency or the truth. It leaves all concerned in a difficult situation, particularly the staff involved-whoever they are.
What we need to know is who is leaving or moving jobs, the reasons why and what interim management arrangements the Trust is making.   And we need to hear this directly from the Trust not via the press.
More on this in due course no doubt, meanwhile:
Creating Barts Health
The values event was part of a series of sessions the Barts Health cultural change team is running to engage staff and others to get feedback on the Board’s values statement. I went along to one of them in the Academic Centre at Whipps representing Health Scrutiny. I counted thirteen people present; two from the security sub-contractor, a number of staff including a former colleague, a hospital chaplain and three members of the patients’ panel from Whipps including the Chair and Vice Chair.
We started off with a presentation led discussion on values which established their importance, “they drive everything we do” and included recordings of two patient interviews, one positive and one not so good. I thought this was a particularly good way of illustrating the issues involved.  It gave a real life feel to the exercise and some of the comments were all too familiar to someone like me who has been a hospital manager.
We then split into groups and listed the sorts of ways in which the indicative values the Barts Health Board had signed up to, ‘Caring and compassionate’, ‘Learning’ and so on could be achieved.
I thought this was good effort on the part of the Trust and everyone present made a contribution. 
One of the more insightful comments from a patients’ panel member was the way in which staffing levels affected the relationship between patients and nurses and midwives ‘I’ve seen them rushed off their feet and it’s hard to chat then...’.  One of the staff made another good point about managers communicating the reasons why things could not be done.
My contribution was about the need for a plan and investment in training.  I also wondered how all of this squared with the £30 million of savings in back office staff the Trust is going to have to make as part of the merger plan.  I guess the real test is whether the Board is prepared to support this type of approach in the longer term or whether it is an opening ’sweetener’ before the realities of their financial situation have to be tackled. 
We shall see, but meanwhile “well done” to the Board for supporting this exercise from the outset.

Monday, June 18, 2012

Time for a reality check at BHRUT

Neil Zammett writes:

I have been reviewing the papers from the North East London and the City (ELC) Board meeting of 30th May and in particular the BHRUT ‘Quality and performance update’.

This covers a number of important items including Board leadership, improvements in emergency care, reducing maternity bookings, cost improvements (efficiency savings) and a long term financial strategy. Of these the reduction in maternity bookings raises a number of new issues of both principle and practice.

The first issue is the proposed 8000 cap on deliveries (page 5 of the report).  This is the first I have heard of this proposal and it has not been the subject of discussion or consultation to my knowledge.   I know that formal enquiries about plans for Maternity Services have been made on behalf of Health Scrutiny in Redbridge to Alwen Williams but I have yet to see a response.

The cap would represent not just a change in referral patterns affecting probably between 2000-40000 women per annum but also a new principle which would have the effect of restricting choice for women.  This is acknowledged at the top of page six of the report:

... and changes to the GP referral patterns/patient choice in B&D and Redbridge.’

I have to say that the next paragraph relating to consistency with Health for North East London decision making is inaccurate.  The third paragraph on page 25 on the Decision Making Business Case (DMBC) makes the principle which the JCPCT decided on very clear and I quote:

However women should be supported to access the campus of their choice regardless of geographical proximity...

It would also be true to say that the Homerton did not feature in this aspect of the plans.

The ‘Cap’ will have a number of implications, 20% less deliveries;  BHRUT did around 10,000 in 2010-2011 the last year before restrictions were introduced, and means in broad terms 20% less income, 20% less midwives and 20% less beds.   In my view it will have a dramatic effect on morale as it throws the expansion of maternity services at BHRUT into reverse and has the potential to force them into a downward spiral of income and standards.

There is also the question of Newham and Whipps being able to cope with the additional numbers.  Whipps has had recruitment problems and recently cancelled home births.  This is why the Homerton is mentioned women will have to travel further to give birth and without much choice.

My view is that the various scrutiny committees should be informally consulted about the principle and asked for their views on formal consultation before any final decision is reached.  There also needs to be a wider discussion on how these changes, and particularly the size of units will affect choices for women and how maternity services in East London will be accessed from each borough.

The average number of deliveries in London is about 4400 per unit but in East London units at Queen’s, Whipps and Newham will have getting on for 9000 each if the plans go ahead.  Only the Liverpool Women’s Hospital which specialises in Obstetrics and Gynaecology has anything approaching this number.

Because of the pressure on services, the moves towards caps and forced changes in referral patterns women will simply have to go where they are directed and most will not have a choice between consultant and midwife led deliveries.

Women and the organisations that represent them along with local authorities need to be made aware of the implications of these changes and given a real opportunity to express their views.

The second real area of concern I had was the section of the report on A&E.  This is restricted to a brief statement on meeting national standards which is indeed a problem.  However, the much more serious problem, not included in the report, is the rise in non-elective admissions and the consequent demands for beds and very high levels of ambulance black breaches.  

It is these emergency admissions which raise the very real possibility that King George A&E cannot be closed, at least not on anything approaching the proposed timescale.  This is of course supported by the comments in the report about the CQC inspection.

Page 10 of the DMBC also laid down very clearly that A&E should be co-located with maternity.  Given the likelihood that closing King George A&E will not be possible it raises a further question about closing maternity at King George.

I felt that the ELC Board were not getting anything like the full picture of A&E from the report and I thought how difficult it must be for their non-executives to make sound decisions at this critical time.

The third issue was the treatment of the very serious financial problems. The overspend last year was an eye watering £49.9 million, in line with control total agreed in month 7 we are told.  Again I would have liked to see more detail. How much of the £49.9 million was planned?  What was the underperformance on the CIP (Cost Improvement Programme)?  Without this and other information I found it very difficult to see how the non-executives could be exercising proper control. 

This is particularly relevant to other sections of the report relating to the 2012-13 financial plan and long term viability.  Ever since its inception BHRUT has had no credible long term financial plan and has struggled to meet year on year targets.  Much of this is down to the now accepted impact of the PFI and without some long term subsidy to offset this BHRUT will never achieve an acceptable financial performance.  Arranging this subsidy is primarily the responsibility of ELC in my view.

Very worryingly page 4 of the report contains statements about a workforce reduction plan for 2012-13.  This is despite the CQC identifying low staffing levels at BHRUT and raising concerns about the proposed reduction in nursing staff in the 2012-13 workforce strategy:

A lack of registered nursing and midwifery staff is also highlighted by the fact that the trust has the lowest ratio of nurses to beds of all London acute trusts.

ELC seem to be in denial about the linkage between quality, safety, staffing levels and costs. Reducing staffing is going to have an inevitable and immediate impact on quality.

Finally there was an equally worrying statement on the same page on delays in reporting serious untoward incidents, particularly as this includes maternity.  Redbridge Health Scrutiny still has to hear from BHRUT about the details of the two maternal deaths which took place in November 2011and other incidents.  Of course delays also means that valuable opportunities to learn from incidents are missed.

Having read the report I was struck with the way in which ELC seem to be pursuing the original plan in the DMBC without taking account of the current situation, particularly in A&E.  More and more pressure to achieve seems to be being placed on BHRUT which was a stressed and underachieving organisation even before ELC started to implement the plan.

In my comments on the DMBC widely circulated in December 2010 I warned about the assumptions made in reducing length of stay (LOS) at Queen’s and King George:

Because trusts were allowed to choose their levels of LOS reduction there was no check on feasibility.  So at the Homerton no gains were forecast which is a very unlikely outcome while at Queen’s/ King George a reduction of 22% was forecast to 2012-14.  The author acknowledges that ‘The Trust and local stakeholders recognise the challenge that this represents.’

What is needed is recognition that the plan is unachievable at least on the timescale that was originally envisaged and for BHRUT to be given some breathing space to tackle some of the staffing and quality issues.  The financial plan should start with an agreed central subsidy for the PFI and work through the relationship between safe staffing levels and costs to give a long term profile of expenditure.

In my experience pressurising people and organisations to do the impossible has predictable and serious consequences.

Thursday, June 7, 2012

Next meeting poster

The above is the poster the next public meeting on 20th July, it would be great if you could display in your window.

Can you help Mail on Sunday

Anyusha Rose is writing an artcile for the Mail on Sunday on KGH, her deadline is tomorrow. Anyusha would like to hear from anyone who thinks they have something interesting to say on the subject, especially the areas in her email to me below, her email is
From: tmos livetemp [mailto: ]
Sent: Wed 06/06/2012 15:41
To: Cllr Walker
Subject: Ward closures

Hi Andy,

I’m looking at writing an article about the effects of the potential closure of the maternity and A&E wards at King George Hospital. At the moment I have just started research and am hoping you can answer a few questions for me.
Firstly, what do you see as the short and long term effects of these changes if they are put into force?
Do you think these reforms were proposed with financial gain rather than the patient as priority?
How likely do you think it is that these changes will be implemented?
I really hope you are able to answer these questions for me.
I look forward to hearing from you.
Anyusha Rose
Live Magazine
The Mail on Sunday
2 Northcliffe House
2 Derry Street
W8 5TT

Sunday, June 3, 2012

How Many Midwives are there at Queen's Hospital?".

Neil Zammett Writes:-
 I have been reviewing the BHRUT papers, in May some 377 pages, trying to pick up on any key issues for Maternity and to my surprise I noted that in the executive summary of the workforce key performance indicators on page 2 the following statement:

Since June 2011, 37.80  Full Time Equivalent (FTE) midwives have commenced in post bringing the total number of midwives in the Trust to 287.35 FTE’s and, as already discussed, demonstrating an increase of 17.89 FTE’s over the 12 month period.

Unfortunately we are also seeing the number of midwifery leavers increasing – since June 2011 we have seen 39.90 FTE leavers.  Midwifery bank and agency FTE bookings increased in March by 6.67 FTE’s on the February position.

The report explains earlier staff in post growth differs from starters and leavers analysis because of timing issues to do with the payroll and changes in hours.
As it stands however the report shows that for the time period June 2011to March 2012 there was an apparent net loss of midwives and an increase on the previous month in bank and agency. My surprise is obviously due to general impression which has been created by the Trust that midwifery staffing and recruitment has improved. 

Going back to March 2011 after an initial report by the CQC, the Trust said:

“Funding is in place to bring 49 extra midwives to the Trust and we have recruited to 50% of these posts in the last week alone.  Further interviews are taking place at the end of this month.  We are redesigning services at Queen’s Hospital to make care safer, and improve the experience of women in labour.” 

 And in October 2011 just after the main CQC report was published the Trust said that:
 “Recruited an additional 72 midwives to ensure one-to-one care for women in labour”.
And yet again in January 2012, this time showing the full press release:

16th January 2012
Director of Nursing Deborah Wheeler said: “We have had great success in recruiting midwives to the Trust. Just this week we interviewed 40 trained midwives for positions at Queen’s and King George, and now have one of the best midwife to birth ratios in London.“
 Towards the end of 2010 the Trust travelled abroad to recruit experienced foreign midwives to the organisation.

“ At that time there was a shortage of midwives in this country and, like many other Trusts, we went to other countries such as Ireland and Belgium to find high calibre professionals.
“ Forty-six foreign midwives were taken on in addition to UK midwives. All passed extensive tests and interviews, and were given a thorough induction to the Trust.

“ Seventeen of these midwives have since left the organisation, while the majority continue to work for the Trust, and have proven to be real asset to the organisation.”
Obviously timing is an important factor there are delays between interviews and appointments and some job offers are not taken up.  The reality however appears to be that in a twelve month period, presumably April 2011 to March 2012 the net gain to the Trust was around 18 whole time equivalent midwives, not 49,72, 46+ or even 29 (46-17).

Presumably some of the Trust’s earlier statements refer to the use of Bank and Agency staff to improve the midwife to patient ratio and also exclude leavers.  I can understand the Trust wanting to put a positive slant on recruitment and I applaud the efforts which have been made but the question has to be asked, is this approach actually going to work in the long term?

Despite all the hype the increase over the last twelve months in midwives is only just over 6% and this will be eroding further over time.  In fairness to the present and past Boards at BHRUT this is not a new problem and I can remember spotting a comment from the university appointee, a doctor, from a few years ago to the effect that ‘we have been talking about recruiting permanent staff for months now but we still rely on bank and agency.  We urgently need to get on and do it’.  Not his exact words of course but the sentiment I remember.

What is important is that we focus on the real problems and not short term solutions which may mask these.  There is a crying need to look across East London at midwifery staffing and to match this to future demand.  Initiatives at BHRUT may simply create shortages elsewhere, or ‘drain’ the overseas recruitment market.  Extensive use of Agency staff pushes up costs and may again put pressure on the pool of midwives available in East London.

I would emphasise that this is not BHRUT’s responsibility but that of East London and the City cluster PCT.