Wednesday, January 30, 2013

No room at the Inn part II

BHRUT declare a major internal incident in A&E and Bart’s Health are forced to buy community beds to support Whipps

A&E at Queen’s and King George has reached crisis point.  From the end of October last year there has been a steady fall off of performance which has seen only 60-65% of patients seen within four hours on some days against the target of 95%.  On average in December the figure was 81% with King George performing much better than Queen’s. The NELC Board papers of 30th January describe Queen’s as having “...sustained and significant underperformance.”

The BHRUT Board meeting on January 9th heard that waits of over eleven hours have been recorded at Queen’s. This is a major blow for the Trust because of the enormous amount of time and money that has been invested in the ‘RESET’ programme over the last six months run by the consultancy firm McKinsey which was supposed to resolve the A&E performance issues.

Looking at the performance graph in the NELC papers one of the most worrying features is the marked downward trend from the middle of October last year until the end of December when the graph finishes.  There is no sign of the trend “bottoming out” and it represents almost a full quarter of rapid deterioration.

At a glance

·        BHRUT have the worst A&E performance figures in London

·        The major incident in A&E has not been fully and openly reported

·        Bed closures are putting unsupportable pressure on patient flows

·        Problems are now being experienced by Whipps and extra community beds are being purchased

·        The commissioners have sent a ‘contract query note’ which will do little to help and will put more pressure on the Trust

·        Closing the A&E at King George is not feasible in the short term and the NHS should look for a longer term solution

A major internal incident

Equally disturbing is the news from the NELC Board papers[: “The level of pressure has continued into early January leading to the Trust declaring an (sic) major internal incident, increasing staffing win the ED (Emergency department) and opening a further 16 beds as contingency capacity and there is no further contingency capacity available.“

What is surprising is that there was no mention of the “major internal incident” in the BHRUT papers.  In fact there is no narrative report at all just a tabular action plan.  There was some discussion of the problems at their public Board meeting with a number of members describing the situation as unacceptable.

Major incidents are usually large scale civil emergencies such as fires or floods which generate many casualties.  It is very unusual for a hospital to declare one for internal reasons and certainly not because of pressure in A&E.  There is a clear requirement in Section 7 of the guidance for the Trust to maintain communication with the local community, the media and VIPs.

A briefing note for Scrutiny members sent out by BHRUT on 21st January does give some basic facts and acknowledges that the long waits are a serious concern but makes no mention of the ”major internal incident” again.

The response from the commissioners has been to increase the pressure on the Trust by introducing a “contract query note” and an action plan to improve the situation. More money is being made available for a fourth stage of ‘RESET’, again with McKinsey.

The origins of the problems

To many of us this situation, desperately worrying as it is, comes as no surprise.  The underlying problems of Queen’s and King George are:

Firstly, that the catchment area of the hospitals is so much larger than others in NE London. The two probably serve upwards of 800,000 to 900,000 people while Newham, Whipps and the other hospitals cover more like 250,000 to 350,000.

Secondly, trying to reduce beds puts unsupportable pressure on patient flows in Queen’s and King George and leads to the diversion of emergency ambulance cases to other hospitals.

Consequently problems at Whipps are starting to emerge as well, with Barts Health having to spot purchase continuing care and rehab beds to relieve the pressure on A&E. The Hospital has been closed to emergency ambulance cases on an unknown number of occasions in December and January. This is against a background of as yet undeclared plans to close community beds by NELC which form an important outlet for discharges. The ominous news that BHRUT have run out of contingency beds underlines the seriousness of the situation.

There may be cross boundary flows to other hospitals and some ‘smoothing’ by the Ambulance service redirecting emergencies when departments are full but this cannot compensate for these two factors.  The bad news is that this can only get worse as the population rises every year and the national trend for increased attendances at A&E departments continues.

Elected members, campaigners and others have been warning about this since the start of the Health4NEL process.

The commissioners’ response

Putting pressure on the BHRUT could be counterproductive and morale must be affected by the situation.  When people are doing their best in difficult circumstances a ‘contact query note’ doesn’t offer much and given that ‘RESET’ and McKinsey have not really solved the problems spending more on this approach may again be counterproductive.

Are BHRUT conforming to the standards in public life?

It is also very worrying in governance terms that a full written report on the situation was not made at the January 9th BHRUT Board meeting. There is also no statement on the website or the newsletter for members about the major internal incident.  NELC are to be congratulated for putting the information in the public domain but there is clearly a responsibility on BHRUT to inform the public and to be open as part of the “Standards in Public Life” agenda.

How to move forward

There needs to be a recognition on the part of the NHS that closing the A&E at King George is not achievable in the short or medium term and to start looking at longer term trends to see how viability for services in NE London could be achieved

We know we have a lot of debt/investment much of it tied up in expensive PFIs, the population is one of the fastest growing in the UK and we have significant workforce issues particularly around Maternity.  All of this needs to be balanced against efficiency gains and the Darzi principles of centralisation and specialisation.

I support these strongly, but there is a growing risk that by attempting to do too much too quickly progress may in fact be slowed down.  What you can do safely in five or ten years you cannot do in two.

CQC Report on Queens A&E copied below

Inspection Report | Queen's Hospital | January 2013 1
Inspection Report
We are the regulator:
Our job is to check whether hospitals, care homes and care
services are meeting essential standards.
Queen's Hospital
Rom Valley Way, Romford, RM7 0AG Tel: 01708435000
Date of Inspections: 05 December 2012
29 November 2012
28 November 2012
Date of Publication: January
We inspected the following standards to check that action had been taken to meet
them. This is what we found:
Care and welfare of people who use services
Action needed
Action needed
Action needed
Inspection Report | Queen's Hospital | January 2013 2
Details about this location
Registered Provider Barking, Havering and Redbridge University Hospitals NHS
Overview of the
Queen's Hospital is part of Barking, Havering and Redbridge
University Hospitals NHS Trust. It offers acute services for
all major specialities to a large and diverse population and
includes an accident and emergency department. The Trust
runs a joint cancer centre with another London hospital, and
is a regional neuroscience centre. We visited the accident
and emergency department.
Type of service Acute services with overnight beds
Regulated activities Diagnostic and screening procedures
Family planning
Maternity and midwifery services
Surgical procedures
Termination of pregnancies
Treatment of disease, disorder or injury
Inspection Report | Queen's Hospital | January 2013 3
When you read this report, you may find it useful to read the sections towards the back
called 'About CQC inspections' and 'How we define our judgements'.
Summary of this inspection:
Why we carried out this inspection 4
How we carried out this inspection 4
What people told us and what we found 4
What we have told the provider to do 5
More information about the provider 5
Our judgements for each standard inspected:
Care and welfare of people who use services 6
Staffing 9
Records 10
Information primarily for the provider:
Action we have told the provider to take 11
About CQC Inspections
How we define our judgements
Glossary of terms we use in this report
Contact us
Inspection Report | Queen's Hospital | January 2013 4
Summary of this inspection
Why we carried out this inspection
We carried out this inspection to check whether Queen's Hospital had taken action to meet
the following essential standards:
Care and welfare of people who use services
This was an unannounced inspection.
How we carried out this inspection
We looked at the personal care or treatment records of people who use the service,
carried out a visit on 28 November 2012, 29 November 2012 and 5 December 2012,
observed how people were being cared for and checked how people were cared for at
each stage of their treatment and care. We talked with people who use the service, talked
with carers and / or family members and talked with staff.
What people told us and what we found
The accident and emergency department (known as the Emergency Department) has not
met most of the national quality indicators as a result of extensive delays in the care of
patients. Five percent of patients who need to be admitted to the hospital are waiting for
more than 11 hours in the department. The Trust should be aiming to transfer 95% of
patients who are being admitted to wards within four hours of their arrival.
This has led to poor care for patients in the 'Majors' area where seriously ill patients are
cared for. The 'Majors' environment is unsuitable for patients to be nursed in for long
periods of time for a variety of reasons such as, lack of privacy/dignity, no washing
facilities, no storage space for personal belongings and no bedside tables. There is a
limited range of food and drink available.
We found that many patients, who were there for a long period of time, including overnight,
were nursed on trolleys when they should have been moved onto a bed. This
increases the risk of them developing pressure damage, dehydration, and an increase in
There are not enough consultant or junior doctors to provide medical care for the number
of people who attend Queen's ED. In the 'Majors' area there are not enough nurses to
provide adequate care for patients.
The Emergency Department Medical Unit (EDMU) had the names, dates of birth and
diagnosis of patients on 'white boards' which were visible to both the public and other
Inspection Report | Queen's Hospital | January 2013 5
You can see our judgements on the front page of this report.
What we have told the provider to do
We have asked the provider to send us a report by 09 February 2013, setting out the
action they will take to meet the standards. We will check to make sure that this action is
Where we have identified a breach of a regulation during inspection which is more serious,
we will make sure action is taken. We will report on this when it is complete.
Where providers are not meeting essential standards, we have a range of enforcement
powers we can use to protect the health, safety and welfare of people who use this service
(and others, where appropriate). When we propose to take enforcement action, our
decision is open to challenge by the provider through a variety of internal and external
appeal processes. We will publish a further report on any action we take.
More information about the provider
Please see our website for more information, including our most recent
judgements against the essential standards. You can contact us using the telephone
number on the back of the report if you have additional questions.
There is a glossary at the back of this report which has definitions for words and phrases
we use in the report.
Inspection Report | Queen's Hospital | January 2013 6
Our judgements for each standard inspected
Care and welfare of people who use services
Action needed
People should get safe and appropriate care that meets their needs and supports
their rights
Our judgement
The provider was not meeting this standard.
People did not experience care, treatment and support that met their needs and protected
their rights.
We have judged that this has a major impact on people who use the service. This is being
followed up and we will report on any action when it is complete.
Reasons for our judgement
We visited the emergency department (ED) at Queen's Hospital because we had identified
major concerns about the care and welfare of patients during a previous visit in March
2012. We carried out this inspection to ensure they had made improvements, in relation to
concerns identified about meeting waiting times and delays experienced by patients in
receiving care and the quality of the care they received.
The ED monitors its performance times for dealing with all patients. For both patients who
are subsequently admitted and those who are not it aims to treat 95 % of them within four
hours. For those patients who do not require admission, since September 2012 the ED
has been meeting this target. However, for those patients who need to be admitted the ED
is not meeting the target and 5% of patients were in the ED for more than 11 hours before
The emergency department is subject to high levels of demand; it was originally built to
deal with up to 90,000 patients, it now sees around 132,000 patients per year. Although
other ED departments in London see more patients, in the financial year 2011/2012
Queen's Hospital had 2,686 'Blue Light' (very serious) ambulance cases which was more
than any other hospital in London.
The department consists of a separate paediatrics, resuscitation, rapid assessment and
treatment (RAT), Majors, Emergency Medicine Decisions Unit (EDMU), where ED patients
can be accommodated for up to 24 hours to assess their condition, and minor injuries area
which is co-located with the urgent care area.
We reviewed information provided by the London Ambulance Service (LAS) for the period
May to November 2012 relating to Queen's Hospital. The report showed that Queen's ED
was responsible for most of the ambulance diverts (when an ED has to close and non- life
threatening admissions and ambulances are diverted to other hospitals) in the North East
London region. For this six month period ambulances were diverted to other hospitals on
Inspection Report | Queen's Hospital | January 2013 7
16 occasions.
The LAS also records "black breaches" (those cases where it has taken over 60 minutes
from the time the ambulance arrives at a hospital, until both the clinical handover and the
patient handover has taken place). For the three month period from January to March
2012 there were 231 recorded "black breaches" at Queen's Hospital. This has recently
improved and for September to November 2012 52 "black breaches" were recorded,
although the Trust believes this figure should be lower and is currently in the process of
reconciling them.
Ambulance patients who are unwell and may need admission are assessed and directed
through to the 'Majors' area; this area consists of 25 bays, 23 used for beds with two bays
being used as a seating area with six seats; it also includes the five RAT cubicles.
Once the hospital has made a Decision to Admit (DTA), a patient they should be moved as
soon as possible from the ED to the main hospital wards or to the Medical Assessment
Unit. On our first day of the inspection at 11am there were 22 patients in the 'Majors' area.
For five of these it was noted that a DTA had been made and six patients had been in the
ED since midnight. One of the patients had been in the ED since 5pm the previous
evening. Patients told us the only drinks they had been offered was that morning with their
breakfast which was toast. One of the female patients we spoke to said she was very
thirsty and we could see that her mouth was dry, there was no information on her patient
records indicating that she her been given a drink since her arrival 11 hours previously.
On the second day of our inspection, at 1030am, there were 30 patients in the 'Majors'
area. Eighteen of them had been in the ED for more than six hours and ten had been in
the ED since before midnight. We examined the patient's records and found that for eleven
of them a DTA had been made and they were waiting for a bed in the medical admissions
unit or main wards in the hospital. Of the 10 patients who had been in since midnight, four
were still on a hospital trolley instead of a hospital bed. We spoke to four of the ten
patients who had been there since before midnight, we found that they had been given
drinks when needed. We noted that their dignity was not always being respected for
example curtains were not drawn when needed and in one case an elderly person's
underpants had been left hanging on the bottom of their bed.
On the third day of our inspection we visited at 4pm and found there were 27 patients in
the 'Majors' area. Eleven of them had been at the hospital for more than four hours and
nine had been there for more than six hours. The longest time a patient had been there
was 14 hours and 43 minutes. Staff told us that nine of the patients were waiting to see
medical specialists from other parts of the hospital. All of the patients were lying on a
hospital trolley. Patients told us that they had been offered water throughout their stay and
sandwiches at lunchtime.
Over the three days of our inspection we spoke to a number of staff in 'Majors', they told
us that the area is not designed to provide ward type care, there is no meal provision other
than soup and sandwiches and no ward furniture, such as lockers and bedside tables, is
provided. Staff told us that we had visited at a particularly busy time but that it was often
very busy and what we had found on our inspection was typical for the ED. They told us
that the problem was the hospital wards were not making beds available so they could
transfer patients. In addition staff said that there were excessive delays in specialist
doctors from other parts of the hospital attending the ED to see patients. We examined
patient's medical notes and confirmed this to be the case; we found two examples where
patients had been waiting for more than seven hours to be seen by a specialist doctor.
Inspection Report | Queen's Hospital | January 2013 8
Inspection Report | Queen's Hospital | January 2013 9
Action needed
There should be enough members of staff to keep people safe and meet their
health and welfare needs
Our judgement
The provider was not meeting this standard.
There were not enough qualified, skilled and experienced staff to meet people's needs.
We have judged that this has a major impact on people who use the service. This is being
followed up and we will report on any action when it is complete.
Reasons for our judgement
We reviewed the number of nurses in the 'Majors' department, which was very busy
during the three days that we were inspecting. Staff also told us that the department was
usually very busy. We examined the staff rotas and observed the actual number of nurses
on duty. We found that there were always four nurses on duty in the 'Majors' area which,
for the number of patients they had to look after, meant their ratio ranged from one
registered nurse to 5.5 patients to one registered nurse for 7.5 patients. We were informed
that the baseline ratio for 'Majors' was a ratio of one registered nurse to six patients at
night and one registered nurse to five patients in the day.
We spoke to some of the nurses in the 'Majors' who told us, " we can cope with the
numbers if things are quiet, but when things get busy there are not enough nurses here".
With regards to medical staff, the Trust has 16 Consultants in the General ED to cover
both Queen's and King Georges Hospitals. They provide an on-site presence from 8am to
10pm Monday to Friday and 6 hours (as a minimum) on Saturdays and Sundays, at each
site. In addition there are two Paediatric Consultants. It currently has 11.6 permanent
consultants in post and provides the rest of the cover by employing locum staff. The Royal
College of Emergency Medicine would recommend that for the number of patients seen at
the ED at Queen's Hospital it should have 16 consultants to provide cover 16 hours a day,
seven days a week. The ED has a number of consultants working between 9am and 5pm
but after 5pm there is often only one consultant available until 10pm. Staff told us that
consultants do not finish their shift at 10pm until they are happy it is 'safe' to do so. After
10pm there is a consultant available on call. The ED at Queen's is under resourced for
Additionally consultants need to be supported by a multidisciplinary workforce that reflects
the case mix and complexity of the workload. There are 29 doctor middle grade posts, of
which only 14 are filled. These doctors work a rolling shift pattern covering both King
George and Queen's Hospitals. The rest of the vacancies are filled by locums. The ED at
Queen's is under resourced for middle grade doctors.
Inspection Report | Queen's Hospital | January 2013 10
Action needed
People's personal records, including medical records, should be accurate and
kept safe and confidential
Our judgement
The provider was not meeting this standard.
Records are not being kept securely
We have judged that this has a minor impact on people who use the service, and have told
the provider to take action. Please see the 'Action' section within this report.
Reasons for our judgement
The ED has an Emergency Department Medical Unit (EDMU) where patients from the ED
can be accommodated for up to 24 hours to assess their condition. The unit consists of
two wards with four bays in each. We looked at the unit in detail and found that it was full
with eight patients. However, only one of them met the criteria for an EDMU patient, all the
others were overflow from the Medical Assessment Unit (MAU) which is a ward that is not
part of the ED and can accommodate up to 60 patients for stays for up to 48 hours before
patients are either discharged or transferred to a main ward.
When we visited the EMDU, we found that patients' notes were securely stored in a
lockable trolley. However, we found that patient's names, dates of birth and a summary of
their diagnosis where written on large 'white boards' that were fully visible to the public and
other patients. We identified this issue to senior staff on the first day of our visit but found
the same situation when we returned on the second day.
This section is primarily information for the provider
Inspection Report | Queen's Hospital | January 2013 11
Action we have told the provider to take
Compliance actions
The table below shows the essential standards of quality and safety that
were not being
. The provider must send CQC a report that says what action they are going to take to
meet these essential standards.
Regulated activity Regulation
Treatment of
disease, disorder or
Regulation 20 HSCA 2008 (Regulated Activities) Regulations
How the regulation was not being met:
To be advised
This report is requested under regulation 10(3) of the Health and Social Care Act 2008
(Regulated Activities) Regulations 2010.
The provider's report should be sent to us by 09 February 2013.
CQC should be informed when compliance actions are complete.
We will check to make sure that action has been taken to meet the standards and will
report on our judgements.
Inspection Report | Queen's Hospital | January 2013 12
About CQC inspections
We are the regulator of health and social care in England.
All providers of regulated health and social care services have a legal responsibility to
make sure they are meeting essential standards of quality and safety. These are the
standards everyone should be able to expect when they receive care.
The essential standards are described in the Health and Social Care Act 2008 (Regulated
Activities) Regulations 2010 and the Care Quality Commission (Registration) Regulations
2009. We regulate against these standards, which we sometimes describe as "government
We carry out unannounced inspections of all care homes, acute hospitals and domiciliary
care services in England at least once a year to judge whether or not the essential
standards are being met. We carry out inspections of dentists and other services at least
once every two years. All of our inspections are unannounced unless there is a good
reason to let the provider know we are coming.
There are 16 essential standards that relate most directly to the quality and safety of care
and these are grouped into five key areas. When we inspect we could check all or part of
any of the 16 standards at any time depending on the individual circumstances of the
service. Because of this we often check different standards at different times but we
always inspect at least one standard from each of the five key areas every year. We may
check fewer key areas in the case of dentists and some other services.
When we inspect, we always visit and we do things like observe how people are cared for,
and we talk to people who use the service, to their carers and to staff. We also review
information we have gathered about the provider, check the service's records and check
whether the right systems and processes are in place.
We focus on whether or not the provider is meeting the standards and we are guided by
whether people are experiencing the outcomes they should be able to expect when the
standards are being met. By outcomes we mean the impact care has on the health, safety
and welfare of people who use the service, and the experience they have whilst receiving
Our inspectors judge if any action is required by the provider of the service to improve the
standard of care being provided. Where providers are non-compliant with the regulations,
we take enforcement action against them. If we require a service to take action, or if we
take enforcement action, we re-inspect it before its next routine inspection was due. This
could mean we re-inspect a service several times in one year. We also might decide to reinspect
a service if new concerns emerge about it before the next routine inspection.
In between inspections we continually monitor information we have about providers. The
information comes from the public, the provider, other organisations, and from care
You can tell us about your experience of this provider on our website.
Inspection Report | Queen's Hospital | January 2013 13
How we define our judgements
The following pages show our findings and regulatory judgement for each essential
standard or part of the standard that we inspected. Our judgements are based on the
ongoing review and analysis of the information gathered by CQC about this provider and
the evidence collected during this inspection.
We reach one of the following judgements for each essential standard inspected.
Met this standard
This means that the standard was being met in that the
provider was compliant with the regulation. If we find that
standards were met, we take no regulatory action but we
may make comments that may be useful to the provider and
to the public about minor improvements that could be made.
Action needed
This means that the standard was not being met in that the
provider was non-compliant with the regulation.
We may have set a compliance action requiring the provider
to produce a report setting out how and by when changes
will be made to make sure they comply with the standard.
We monitor the implementation of action plans in these
reports and, if necessary, take further action.
We may have identified a breach of a regulation which is
more serious, and we will make sure action is taken. We will
report on this when it is complete.
action taken
If the breach of the regulation was more serious, or there
have been several or continual breaches, we have a range of
actions we take using the criminal and/or civil procedures in
the Health and Social Care Act 2008 and relevant
regulations. These enforcement powers include issuing a
warning notice; restricting or suspending the services a
provider can offer, or the number of people it can care for;
issuing fines and formal cautions; in extreme cases,
cancelling a provider or managers registration or prosecuting
a manager or provider. These enforcement powers are set
out in law and mean that we can take swift, targeted action
where services are failing people.
Inspection Report | Queen's Hospital | January 2013 14
How we define our judgements (continued)
Where we find non-compliance with a regulation (or part of a regulation), we state which
part of the regulation has been breached. We make a judgement about the level of impact
on people who use the service (and others, if appropriate to the regulation) from the
breach. This could be a minor, moderate or major impact.
Minor impact
people who use the service experienced poor care that had an impact on
their health, safety or welfare or there was a risk of this happening. The impact was not
significant and the matter could be managed or resolved quickly.
Moderate impact
people who use the service experienced poor care that had a
significant effect on their health, safety or welfare or there was a risk of this happening.
The matter may need to be resolved quickly.
Major impact
people who use the service experienced poor care that had a serious
current or long term impact on their health, safety and welfare, or there was a risk of this
happening. The matter needs to be resolved quickly
We decide the most appropriate action to take to ensure that the necessary changes are
made. We always follow up to check whether action has been taken to meet the
Inspection Report | Queen's Hospital | January 2013 15
Glossary of terms we use in this report
Essential standard
The essential standards of quality and safety are described in our
Guidance about
compliance: Essential standards of quality and safety
. They consist of a significant number
of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 and the
Care Quality Commission (Registration) Regulations 2009. These regulations describe the
essential standards of quality and safety that people who use health and adult social care
services have a right to expect. A full list of the standards can be found within the
Guidance about compliance
. The 16 essential standards are:
Respecting and involving people who use services - Outcome 1 (Regulation 17)
Consent to care and treatment - Outcome 2 (Regulation 18)
Care and welfare of people who use services - Outcome 4 (Regulation 9)
Meeting Nutritional Needs - Outcome 5 (Regulation 14)
Cooperating with other providers - Outcome 6 (Regulation 24)
Safeguarding people who use services from abuse - Outcome 7 (Regulation 11)
Cleanliness and infection control - Outcome 8 (Regulation 12)
Management of medicines - Outcome 9 (Regulation 13)
Safety and suitability of premises - Outcome 10 (Regulation 15)
Safety, availability and suitability of equipment - Outcome 11 (Regulation 16)
Requirements relating to workers - Outcome 12 (Regulation 21)
Staffing - Outcome 13 (Regulation 22)
Supporting Staff - Outcome 14 (Regulation 23)
Assessing and monitoring the quality of service provision - Outcome 16 (Regulation 10)
Complaints - Outcome 17 (Regulation 19)
Records - Outcome 21 (Regulation 20)
Regulated activity
These are prescribed activities related to care and treatment that require registration with
CQC. These are set out in legislation, and reflect the services provided.
Inspection Report | Queen's Hospital | January 2013 16
Glossary of terms we use in this report (continued)
(Registered) Provider
There are several legal terms relating to the providers of services. These include
registered person, service provider and registered manager. The term 'provider' means
anyone with a legal responsibility for ensuring that the requirements of the law are carried
out. On our website we often refer to providers as a 'service'.
We regulate against the Health and Social Care Act 2008 (Regulated Activities)
Regulations 2010 and the Care Quality Commission (Registration) Regulations 2009.
Responsive inspection
This is carried out at any time in relation to identified concerns.
Routine inspection
This is planned and could occur at any time. We sometimes describe this as a scheduled
Themed inspection
This is targeted to look at specific standards, sectors or types of care.
Inspection Report | Queen's Hospital | January 2013 17
Contact us
Phone: 03000 616161
Write to us
Care Quality Commission
Newcastle upon Tyne
Copyright Copyright © (2011) Care Quality Commission (CQC). This publication may
be reproduced in whole or in part, free of charge, in any format or medium provided
that it is not used for commercial gain. This consent is subject to the material being
reproduced accurately and on proviso that it is not used in a derogatory manner or
misleading context. The material should be acknowledged as CQC copyright, with the
title and date of publication of the document specified.

CQC Press Release on Queens

CQC press release copied below, how can KGH A&E be closed now?
Press release
Regulator finds that A & E department at Queen’s Hospital, Romford, is still failing to protect the safety and welfare of people
  1. But inspectors find that improvements have been made to maternity services by Barking, Havering and Redbridge University Hospitals NHS Trust
    The Care Quality Commission (CQC) has found that some people attending the Accident and Emergency (A & E) department at Queen’s Hospital, Romford, are still receiving unacceptably poor care.
    Inspectors – supported by clinical experts - visited the hospital unannounced in November and December last year. They found that some people who needed to be admitted to the hospital faced a long wait in A & E in conditions which failed to meet their needs. A report on their findings has been published today.
    CQC found that:
    People using the ‘majors’ area who required admission were waiting far too long to be transferred to other parts of the hospital; 5% waited for more than 11 hours.
    Some people were being nursed on trolleys when they needed to be moved into beds. People were at increased risk of pressure sores, dehydration and falls.
    The ‘majors’ area did not have any washing facilities or storage for personal possessions, and didn’t offer people the privacy and dignity they are entitled to. Elsewhere in the department, personal information – including diagnosis - was displayed where anyone, including other members of the public, could see it.
    There were not enough consultant or junior doctors in the A & E.
    Another unannounced inspection, into maternity services at Queen’s Hospital, Romford, found that the required standards there were now being met. A full report on that inspection has also been published today.
    Matthew Trainer, Deputy Director of CQC in London, said:
    "People who need to be admitted to Queen's Hospital through A & E are waiting far too long.
    "No-one should wait 11 hours plus to be transferred to a bed, but some of the people we saw during our unannounced inspection had done just that. The area in which they were waiting was not set up to deliver good quality care to the standard CQC expects.
    "CQC’s plan is to place a legal restriction on the number of people who can be admitted to the ‘majors’ part of A & E if people already there have been waiting for too long. This is designed to protect people from the risk of harm, and to give the Trust breathing space to make the changes it needs to make. We are meeting the Trust Development Authority and local commissioners next week to discuss next steps."
    "Put simply, there are not always enough staff to care for the number of people who are attending the A & E and not enough beds being made available in the rest of the hospital. The Trust has acknowledged this and now needs to put all its energies into putting it right.
    "The significant improvement we have seen in maternity in the last year - both through our inspections, and through patient surveys which say 96% of women giving birth there would now recommend it to family and friends - is a massive step forward. The staff in maternity have worked hard to transform the service. We need to see this kind of fundamental transformation in their emergency care.
    "Decisions about how services are delivered are for trusts and commissioners to make. CQC expects its national standards to be met however services are configured."
    "We’ll be checking the quality of care through further unannounced inspections."
    About the Care Quality Commission
    The Care Quality Commission (CQC) is the independent regulator of health and social care in England. We make sure that care in hospitals, dental practices, ambulances, care homes, in people’s own homes, and elsewhere, meets government standards of quality and safety - the standards anyone should expect whenever or wherever they receive care. We also protect the interests of vulnerable people, including those whose rights are restricted under the Mental Health Act.
    We register services if they meet government standards, we make unannounced inspections of services, both on a regular basis and in response to concerns, and we carry out investigations into why care fails to improve. We continually monitor information from our inspections, from information we collect nationally and locally, and from the public, local groups, care workers and whistleblowers. We put the views, experiences, health and wellbeing of people who use services at the centre of our work and we have a range of powers we can use to take action if people are getting poor care.

    Queens A&E to have cap imposed

    A recent CQC investigation of Queens A&E found waiting times of up to 11 hours.

    The BBC report is here:

    According to the report Queens A&E is to have a cap put on the numbers of patients who will be able to use the A&E.

    This comes after an NHS press release stated earlier this month:
    Attendance Statistics
     • Queen’s A&E has seen a 22% (26,859 patients) rise in attendances from 2011 to 2012.
     • In 2012 Queen’s saw 73 patients a day more than in 2011. • In 2012 Queen’s had 23 days where there were more than 470 A&E attendances. In 2011 there were three days where there were more than 470 attendances. • The average number of attendances a day in 2012 was 404. In 2011 it was 331.
    The highest number of attendees in one day in 2012 was 518.
    Too many patients are having to wait too long to complete their care in our Emergency department (A&E). The target is for 95% of patients to leave the department in under 4 hours, either to be admitted to a hospital bed, or to be treated and return home. Only 81% of our patients were cared for in this timeframe in December.
    This is a very serious concern for us, and a problem that has a number of causes. There are issues with medical staffing, flow through our hospitals, delayed discharges, and the sheer volume of attendances. We are working across the hospitals to reduce delays and free up hospital beds. We are also working with our partners in primary care and social care to reduce avoidable admissions and delayed discharges. We are working to address this problem and will keep you updated on our progress.ENDs
    The A&E closure plans for King George Hospital have to be abandoned now, to do anything else would be irresponsible. Attendances at Queens A&E are rising sharply, as a consquence a cap is to be imposed, KGH has to stay open because Queens cannot cope with the demand.

    Wednesday, January 16, 2013

    3 A&Es closed to ambulances on one day

    Below is an extract from Hansard showing a question asked by Mike Gapes MP

    T4. [136860] Mike Gapes (Ilford South) (Lab/Co-op): On 30 December, ambulances in north-east London were diverted from the Whipps Cross, Queen’s and Homerton hospitals, with only the accident and emergency
    15 Jan 2013 : Column 734
    units at the Royal London hospital and the King George hospital in Ilford being open. Last week, on 8 January, Queen’s hospital in Romford was again diverting ambulances. Will the new Secretary of State look at the decision of his predecessor, whom I see on the Bench near him, and cancel the insane decision to close the accident and emergency unit at King George hospital?
    Mr Hunt: The decision has been taken, but we have made it absolutely clear that we will not proceed with implementing it until there is sufficient capacity in the area, particularly at Queen’s hospital in Romford, to cope with any additional pressures caused by it, and that undertaking remains.ENDs

    Three East London A&Es closed to ambulances on one day is a worry. I have asked NHS for information about temporary A&E closures and will report further when I get a response.

    Monday, January 14, 2013

    No room at the Inn? Maternity Department Capacity in NE London

    Neil Zammett writes
    The last few months have seen the publication of a number of key documents relating to the future capacity on maternity departments in NE London. These are listed at the end of this blog.
    These are all substantial documents which together show how maternity services are going to be provided over the next three years and provide more limited information on the situation in seven year’s time. They do not all cover the same ground, and some are much more detailed than others. This makes piecing the material together to give a full picture a very substantial task in its own right.
    As this is a long blog the headline facts and issue are summarised below:
    At a glance
    · Forecasts have changed and are less certain but birth rates in NE London are still rising and numbers are likely to be about 40,000 per annum in ten years time.
    · In the long term, ten years time plus, six rather than five maternity units are likely to be needed, particularly if an 8000 delivery “cap” is introduced.
    · Under current plans over 50 midwives will be lost at BHRUT. These valuable staff may be lost to the NE London health economy.
    · Only BHRUT has a maternity workforce plan. None of the other trusts have plans available to address the shortfalls in consultants and midwives.
    · The original plan assumed that developments at Whipps would be completed before King George closed. These have yet to be agreed.
    · Without further significant capital expenditure NE London will run out of maternity capacity very quickly unless the unit at King George is retained.
    · The failure to close the A&E department at King George adds weight to the case for retaining a maternity unit there.
    The Forecasts
    All agree that the number of births per annum in NE London is going to rise over the next three to seven years; the question is by how much. The original DMBC from 2010 which was the basis on which the decision to close the unit at King George was made used a single forecast of 36,784 for 2016-17 based on a projection of historical births. These were then apportioned between hospitals using assumptions based on existing flows and a variant based on allocating women to their nearest unit.
    This however was a five year forecast from a 2010-11 base year. No ten year forecast was included in the plan but doubling the five year forecast would give a figure of 44,217 for 2019-20.
    The more recent paper has revised these forecasts to reflect the slowing of the rate of increase in births and now gives two figures based on high and low estimates of the increase in future birth rates. This would give a low figure of 32,940 by 2016-17 and a high of 34,435. The corresponding figures for 2019-20 would be 34,778 and 37,593.
    Given the elapsed time however these are three and seven year forecasts. To get five and ten year projections from a 2013-14 base an extra two years growth, say 2000 deliveries would need to be added. This would give a figure of just under 40,000 births in ten years time as an upper estimate.
    To complicate matters further, the later paper introduces the concept of a permanent “cap” on deliveries on any one site to 8000. Previously the idea of capping had been limited to short term limits on BHRUT. If accepted this would mean that the five proposed units in NE London would have an absolute limit of 40,000 deliveries per annum. Current capacity is estimated at 30,927
    Capping therefore has a direct link to the number of units and is a major policy development which has not been subject to any wide discussion and was certainly not included in the original decision-making process. It also reduces the flexibility in provision. If births exceed 40,000 then six units not five will be required.
    Given the uncertainty in the forecasts and the introduction of capping the need for flexibility in the short and long term plans is magnified.
    How this affects the individual units.
    This again is a complex area because the capacity of individual units depends on both the numbers of staff available and the physical constraints of the unit; theatres for caesareans, delivery rooms and so on. All of this is explored in some depth in Geoff Sanford’s paper. He comments:
    “Demand is likely to exceed capacity at most hospitals at some point in the next five years. Much of this demand can be met in the short term by increases in workforce and introducing new ways of working such as co-located birthing units and increasing home births. However there will probably still need to be an increase in the physical capacity for deliveries in the sector to meet the demand in the medium long term.”
    Queens and King George
    BHRUT have very advanced and detailed plans for the closure of the unit at King George and the introduction of the 8000 births cap. These include a schedule for reductions in staffing levels to match the workload. Table 14, page 15 of their Maternity Transition plan shows that WTE midwives are planned to reduce from 321 in October 2012 to 268 the following year, some 53 staff. This is subject to review every quarter to make sure the service remains safe.
    In addition one Consultant, one middle grade and one SHO will be shed from the medical establishment.
    There is adequate infrastructure at Queen’s for up to 9000 deliveries per annum.
    Whipps Cross
    The unit here is considered to be at full capacity with 5,700 deliveries. This is why new proposals to divert Waltham Forest women to the Homerton have been introduced to make way for Redbridge women displaced from King George. Any long term increase in capacity would be dependent on a capital scheme which is currently with NHS London. Lead time would be at least two years.
    Geoff Sanford comments “... demand is likely to exceed this year’s capacity in 2013-14.” This is particularly interesting as the assurance process for the closure of King George shows Newham as green. Staffing is obviously the key issue at Newham although there are some issues about theatre capacity as well.
    The Royal London
    This unit has been under pressure because of a “spike” in births in Tower Hamlets. Outturn in 2011-12 was 4460 deliveries. There is no MLU a present and this would be one route for longer term expansion.
    The Homerton
    Geoff Sanford reports that the Homerton can deal with future demand and possibly increase beyond its current 6000 capacity.
    What is worrying about this is that, as with all the units referred to above apart from Queens, the Maternity Workforce Strategy shows that there is a very significant shortfall at the unit in both midwives and consultants, 58 and 13 respectively up to 2016-17.
    Workforce Planning
    The Maternity Workforce Plan, a broad brush document produced by NELC in May 2011, shows all trusts as having very significant staffing shortfalls for both consultants and midwives. The only Trust to have a detailed workforce plan is BHRUT which is currently the best staffed. The others have no available plans and In particular there is no indication of how the 98 hour cover target for consultants and more aspirational 168 hour target are going to be reached.
    The situation with midwives is even more bizarre with BHRUT planning to lose over 50 staff while other units still have very large shortfalls. This will mean moving births away from a well staffed unit to ones which are worse off.
    Will there be room at the Inn?
    The answer to this question is; in the long term only if there is significant further investment in maternity services and the total number of births remains below 40,000 per annum. It looks very possible that this figure will be exceeded in ten years time and that a sixth unit will be required.
    In the short term the capacity of units is likely to be limited to around 31,000 unless staffing levels can be improved. Given that the demand forecast for 2013-14 is 31,071 to 31,415 the situation is going to be very tight indeed particularly with the reduction in flexibility created by the cap of 8000 on Queen’s.
    Women may have to travel further to have their babies and possibly change units at short notice because of daily spikes in demand. Under these conditions they will have no choice and it is possible that women may have to access units outside NE London in significant numbers.
    The quality assurance process introduced by NELC reconciles demand and capacity for Newham, BHRUT and the Homerton for 2013-14. The outline of the process is shown in paragraphs 1.5 to 1.9 of the “Update of Maternity Services.” The paper lacks detail however and in particular staffing numbers and their relationship to quality standards. It refers to working towards the defined standards rather than achieving them.
    Given the significance of the staffing issues, and the comment in Geoff Sandford’s paper that at Newham demand will exceed capacity in 2013-14, the reconciliation with additional workload should be in the public domain.
    There is a danger of the commissioners being seen to have double standards where BHRUT is expected to meet targets because of the pressure to close the maternity unit at King George and other units are not. This is even more galling because of the efforts BHRUT have made to recruit staff including the overseas drive. If these 53 midwives and three doctors are lost to the NE London health economy they could be impossible to replace.
    How this relates to strategic plans
    The plans for maternity services were not drawn up in a vacuum. In particular they were closely linked to proposals to close A&E at King George. To date it has not been possible to close the department and it now seems likely that it will remain open for the foreseeable future. This is tied up with the development of a long term financial model (LTFM) for BHRUT which is proving problematic.
    Barts Health is also experiencing financial problems and across NE London there are issues with the level of debt/investment much of which is tied up in very expensive PFIs. There has to be a question mark about the financial viability of new investment at the Royal London and Whipps sites. Without this however NE London will soon run out of maternity capacity.
    The zero cost option of using the maternity facilities a King George as a long term sixth unit has not been considered, although this would provide the necessary flexibility and resilience. It would also help to retain over 50 valuable midwives in NE London.
    As the stalling of the A&E closure plans at King George illustrates only too well; there are grave dangers in trying to do too much too quickly, what you can do safely in five years you cannot do in two.

    “Planning for future maternity Capacity in NE London” (Geoff Sanford). First tabled at the JHOSC, 8th January 2013
    “BHRUT Update” (Averil Dongworth). To be presented to the Redbridge HSC, 16th January 2013
    “Update on Maternity Services” (Helen Brown). To be presented to the Redbridge HSC, 16th January 2013.
    To these should be added the following earlier documents:
    “Maternity Workforce Strategy for NE London” May 2011. First tabled at Redbridge HSC, 22nd October 2012.
    “Decision making Business Case (DMBC)” Presented at JCPCT meeting December 2010.