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.

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