Neil Zammett writes
Just before they ‘closed for business’ NELC the umbrella commissioning organisation in East London produced a series of charts of the performance of A&E at Queens and King George for the financial years 20011/12 and 1012/13. What these showed is that performance against the 4 hour wait target; the most widely used measure, is very variable over the year and has a marked seasonal pattern. It has long been believed that A&E waits are longer in the winter months and the charts bear this out but because they are detailed and cover two years they allow us to look at the seasonal effect in much more details. At both King George and Queens the pattern in each year is very similar but also that the two hospitals have very different characteristics.
Queens’ chart was far more ‘peaky’ with a short summer high between the middle of June and the end of August. King George on the other hand had a much longer high between the beginning of April to the end of October, seven months as opposed to two and a half. For both hospitals the results for 2012/13 seemed worse that for 2011/12.
I could only observe a better consistent performance for the month of October. I checked out the overall pattern to see which was more typical and compared with the figures for Greater Glasgow and Clyde for 2010/11. This is another large conurbation and while there may have been some smoothing effect because of the large sample of hospitals the pattern was much more like King George’s with a sustained summer peak. The Trust has produced more up to date figures for 25 March to 21 April 2013 for their May Board meeting. Disappointingly at Queens these show an achievement of around 80% against the 95% target pretty much the same as the last two years.
Interestingly and perversely the Board report states that “Much progress has been made.... and performance has improved particularly at King George.” Again comparing with the NELC charts my observation would be that performance at King George is about the same as two years ago. The problem here is that monthly results are being looked at in isolation which does not take account of the strong seasonal effect at both hospitals. This is very dangerous because if could lead to major decisions being made in the mistaken belief that the Trust has improved its performance when in reality what is being observed is the seasonal upswing which masks an underlying worsening of performance.
Redbridge Health Scrutiny Committee had a good example last November when BHRUT staff presented the RESET (Rapid, End-to-End, Sustainable, Emergency, Transformation) programme for A&E and claimed that the Trust had improved. This was of course at the end of the summer ‘upswing’ and the service deteriorated in the following months. In early January a major surge required extra beds and the re-deployment of staff from other departments. The presentation also stated: “Changes have freed up 114 beds, now reallocated for other uses, without worsening patient flow.” The reality as the NELC charts show is that the service was better in 2011/12 before the RESET programme started.
CQC of course have produced a highly critical report based on visits in late November/early December 2012. All of this means that local people have had to endure a highly unsatisfactory service for over two years with the Trust and the commissioners no nearer to finding a solution. The McKinsey’s RESET programme was intended to embed different ways of working, improve flow and help the Trust deliver sustainable solutions. If it has achieved anything it certainly has not been reflected in the 4 hour wait target. How safe the service is, is a matter for debate.
CQC’s conditions, suspended for the present, would include a limit of 29 patients in Majors and one exceeding four hour, conditions which the BHRUT believes are unworkable. Views from the BHRUT Board Members of the Board are starting to raise awkward questions and the following in italics are direct quotes from Board minutes over the last few months
Anthony Warrens, the University representative and a very eminent academic doctor commenting on the 4 hour access improvement plan in the minute of the March meeting states that: “... the ratings in the plan were not consistent and this had been talked about quite a lot and had been held up as ‘real major progress’. It was obviously not as embedded in practice within the organisation as the Board has been led to understand.”
More worrying are the notes of the Extraordinary Board meeting of 3 April which include the statement that 35 of the emergency department’s posts are being advertised and this was a clear indication of problems in recruitment. Elsewhere in 1st May papers the Workforce Performance Report records the turnover in Emergency Care as 27.4%, twice the Trust average. Maureen Dalziel one of the Non-Executive Directors, a very experienced public health doctor and Chief Executive, had been on two ‘walk-rounds’ of the department. She comments: “...there had been an increase in the number of breaches and she was concerned in the last two weeks that the Trust was heading towards a critical level.”
The Chair, Sir Peter Dixon: “...urged Members to enforce rapid approach as the changes were not being made quickly enough and it was taking too long to resolve issues.” The Board notes end with the bombshell news from Averil Dongworth, the Chief Executive that the: “... Clinical Director of A&E had resigned and that the Trust would be going out to advert and recruiting a new CD (Clinical Director) to take over on 1 May 2013.”
Comment It is difficult not to gain the impression that A+E is in some form of crisis moving steadily towards greater staffing instability and failing to improve on key performance indicators. We all want BHRUT to improve and provide good services but as the Chair Sir Peter Dixon put it: “.... the Trust has yet to grasp the situation.” What I find most worrying however is the historical data which shows that the performance of A&E is worse now than it was two years ago a point which appears not to have been made clear to the Board
It is vital that Board members and others are made aware of this and the significance of seasonality before any key decisions about the future are made particularly in relation to A&E. I am also concerned that the Trust is ploughing on with bed closures against a background of worsening performance. Although much is made in various Board reports of the need for leadership and the responsibilities of partners, we have to look no further than the closure of the 114 beds, about 10% of the total, to find the root cause of the problem. Closures of this order must have affected patient flows but they have not been the subject of any public Board discussions.
A way forward
As someone who monitors the Trust’s performance, it strikes me that the Board itself needs to recognise that they are the custodians of leadership and as such should be getting to the bottom of the problems. Sir Peter is absolutely right the Trust has yet to grasp the situation and they are not going to until they get a fuller picture of the impact of bed reductions. I am not suggesting that rising demand and the other factors are not relevant issues. Of course they are but none of them are new and they are much less likely to have had an effect than the closure of large numbers of beds. Instead of using McKinsey’s on programmes like the RESET which have had little impact, the commissioners would be much better advised to direct their attention to the statistical data and asking McKinsey’s to look at this instead. The whole question of bed usage and future forecasts needs to be revisited in an objective way without making the assumptions that services at King George will close. There should also be a moratorium on further bed closures until the position on A&E has stabilised