A&E at Queen’s-Where will the new NHS take us?

Neil Zammett writes

Last week saw the publication of the latest CQC report on A&E at Queen’s based on their visits on 21st and 22nd of May. As before it is a catalogue of miserable news for patients with unacceptable delays, large numbers of ambulance diverts, shortages of key staff and large numbers of patients waiting for more than an hour in ambulances (black breaches). On this occasion however the visits took place in the spring/early summer when the pressures on A&E are normally easing

On the positive side some improvement in personal care and refreshments for patients waiting was reported.

In a hard hitting press release CQC point out that this has been going on since 2011 and state:

“The emergency department at Queen’s hospital in Romford is failing local people. This situation has been going on for far too long. Radical thinking is needed by the Trust Development Authority and commissioners.”

The evidence base

The former NELC cluster PCT produced occasional reports on A&E which were of good quality and contained year on year comparative data on the four hour wait performance at Queen’s.

(I cannot get graph up at 17.7 AW)

The March 2013 report shows that in 2012-13 the 95% performance was only reached in one week, 29th July and fell below 2011-12 for much of the rest of the year. The graph also shows the seasonality in performance very clearly

Rough comparison of more recent data shows that June 2013’s performance is some five percentage points worse than June 2012 which in turn was the worst year of recent times.

A more formal statistical analysis would show the significance of this year on year variation and this should be done by CQC and the commissioners. However, inspection shows fairly clearly that year on year the performance at Queen’s has declined steadily since the decision to close King George A&E in December 2010.

BHRUT’s response

Perhaps significantly the Chief Executive’s response to stakeholders does not contain an apology this time or the promise of an action plan but simply a reference to their June newsletter.

There is a restatement of some of the major points in the report and news that five joint appointments of A&E doctors with Barts are on the way. BHRUT feels the ambulance service should be taking more patients to Whipps and elsewhere and that they being unfairly loaded.

On the BBC News the Trust spokesperson also cited difficulties with accessing primary care as one of the reasons for the poor performance when commenting on the report.

As always there is reference to the increase in workload and the physical limitations of a department which was designed for a much smaller number of attendances. There are comments about continuity of care across the week and centralisation of specialties but no specific details.

What was not mentioned is the number of beds which have been closed as the Trust reconfigures to prepare for the closure of A&E at King George. It is also evident that BHRUT are keeping separate records of key indicators such as the number of “black breaches”, the number of patients waiting in ambulances for more than one hour. For January to March this year the Trust said it had 23 while LAS figure was 144.

The response of the CCGs, the “commissioners”

The Chair of Havering CCG in an interview on BBC news made it clear that the current situation in unacceptable and both for patients and commissioners. “They’ve done it for maternity now they must do it for A&E; it is a tougher nut to crack...”

There is more in the Ilford Recorder “Significant changes need to happen and they need to happen now...As strong GP commissioners we won’t hesitate to take appropriate action where we feel it is needed.”

There are no specific actions identified however.

Looking at the Emergency Care report to the April Redbridge CCG Board meeting gives some clues as to what the GP’s have in mind so far. It suggests using leverage through the contract and renaming the “Emergency care Standards Performance” group as an “Urgent Care Board”, enlarging its membership and getting it to meet more often.

It is not clear what “leverage” means or how the renaming of the board/group could promote change.

Previously CQC and the commissioners met with NHS London for risk “summits”-the last was in February this year. This meant that all the major parties agreed a way forward. With the demise of NHS London this important coordinating role appears to have lapsed.

Making Decisions

It is hard to read the latest CQC report without feeling that is more of the same and that the situation is now drifting without any firm managerial grip either within the Trust, the commissioners, CQC or NHS England.

There are also worrying signs that as performance worsens the organisations involved are squaring up to blame each other if a crisis occurs.

The NHS Trust Development Authority (TDA) and NHS England are keeping a low public profile and without the risk summits organised by the now defunct NHS London there appears to be no one to pull the different strands together.

To some extent they are all victims of a market structure which has emphasised competition and created a situation where accountability is now so diffused that decision making is both tortuous and slow. Before the current re-organisation things were difficult, now without NHS London they seem to be becoming impossible.

All of this has worrying echoes of the situation in Mid Staffordshire Hospital, not in terms of death rates, but decision making.

The Reasons for the crisis

Right from the outset it has been clear that Queen’s and King George are serving a much larger catchment area than other hospitals in NE London. Rough estimates would suggest 750,000 as opposed to 250,000 to 300,000 at the Homerton and the Royal London for example. It is no wonder therefore that more ambulances are sent to the two hospitals.

BHRUT have also been steadily reducing beds since December 2010 when the decision to close A&E at King George was made. A report to the Redbridge Health Scrutiny committee in September 2012 showed that 114 across the two sites had been closed and reallocated for different purposes. More recent correspondence states that another 60 beds are due to close soon. Quite where this leaves the acute bed base at BHRUT is unclear.

Closing beds when workload is rising is clearly counterintuitive and CQC have identified bed availability as one of the reasons for delays in A&E.

The underlying problem is that no one is prepared to face the unpalatable truth that closing the A&E at King George cannot be achieved without placing the whole of the A&E service across East London at risk.

We have already had a “major surge”, reported as a major internal incident by the commissioners at Queen’s in early January this year and a “significant internal event” at Whipps on April 11th. These happened on different dates but show the potential for a “domino” effect particularly as the Royal London has reported difficulties as well.

Hopefully the “radical thinking” CQC are talking about is recognition that an A&E with a significant acute bed base needs to be maintained at King George for the foreseeable future to ensure patient safety.

CQC however have missed a central point, radical thinking is going to have a price tag associated with it. The improvements in maternity services at Queen’s were only achieved by substantial investment in staff in both medical and midwifery staff by the commissioners. Whether it is more doctors or more beds it is going to cost money which the local commissioners do not have. This is particularly true of Redbridge who have taken a £20 million “hit” in their allocation this year.

The way forward

One of the most worrying aspects of the current situation is that no new thinking has been brought to bear on the situation and here is no new action plan. CQC are right that radical thinking is necessary but have not helped the decision making process by specifying what that might be.

The following is a practical way forward:

Resumption of the risk summits to be chaired by NHS England

An immediate moratorium on bed closures cross NE London

An urgent review of A+E services across NE London to look at capacity and demand and to include a statistical analysis of historical data.

BHRUT to open 60 additional beds in September/October 2013 and a further 30 beds in January 2014, funded by NHS England

Six additional A&E consultant posts to be funded by NHS England

CQC to step in and resolve the dispute about black breach figures with LAS and BHRUT

Neil Zammett

July 2013

Addendum

Just before this Blog was due to be published the CCGs circulated a note outlining their response t the CQC report. By and large this follows the line taken in their comments to the press and the Board paper referred to above.

There are additional statements about community teams, improving discharge services and improving the quality of services in community hospitals and home. There are no details however and the response does not mention the beds that are planned to be closed in community hospitals which are the subject of a separate enquiry by the Redbridge Health Scrutiny Committee.

It seems very doubtful that the actions mentioned would meet the requirement for “radical thinking” from CQC.

NZ