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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