More beds need to be opened now to avert an A&E crisis at Queen’s and King George

Neil Zammett writes The BHRUT Board paper for November show that A&E services at Queen’s and King George have now reached a tipping point. The Trust acknowledges that it needs around 100 extra beds to cope with winter pressures but so far has only identified about 30. Performance on the four hour target of 95% shows a sharp deterioration in the latter part of October, see the graph below taken from the BHRUT Board papers, which if extrapolated would see a dip to around 70% sometime in November. This is unprecedented for this time of year. The Trust’s own forecast shown as a dotted line is pure speculation. The reason for this sharp decline in performance is the relocation of services from King George to Queen’s as part of the implementation of the Health4NEL plan. The Background Back in July this year I blogged about the performance of A&E at Queen’s and provided a detailed evidence base for my concerns: Allowing for seasonal fluctuations performance has deteriorated year by year. This is associated with bed closures at the Trust, 114 by September 2012. I proposed that there should be a moratorium on bed closure across NE London until A&E capacity had been reviewed. I also proposed a phased opening of beds at BHRUT to cope with winter pressures, 60 in September/October and further 30 in January 2014. In reality BHRUT closed Holly Ward in September as part of a planned relocation of services from King George to Queen’s to enable 7 day working losing a further 30 beds, making a total of nearly 150. The Trust initially claimed that this was because they needed fewer beds because of an improvement in cover from senior specialist doctors. It is important that we are all clear about bed closures because the November BHRUT board papers, summarised below, acknowledge that bed shortages at King George and Queen’s “...are the dominant reason for failure of four hour target sic.” (Page 125) This supports the conclusions of my earlier Blog. Previously the Trust has been emphasising the lack of permanent senior medical staff in A&E as the main reason for poor performance and advanced this as a reason for closing King George A&E to blue light cases at night. Now it is clear that this is a more minor factor. An update from the November BHRUT Board papers Details of the A&E position and bed availability are mentioned at different places in the November BHRUT Board papers and for ease of reference are summarised below as direct quotes: • Mr Burgess (Deputy Medical Director) confirmed...as part of Health4NEL the Trust was closing beds at King George Hospital; one in September (Holly Ward) and another ward which would be identified, to close in March 2014... The Trust was looking at six wards coming out as part of its reconfiguration programme. (Page 13) • The trust bed requirement sees an underlying seasonal increase of c100 beds (driven by general medicine and geriatrics). With limited headroom sic and an average occupancy of 97%, this translates into a significant bed capacity gap. (Page 19). • In planning for 7 day working the medical teams had expected to realise a reduction in length of stay (LoS)...Close monitoring of the impact of all these changes was undertaken weekly and what became apparent was that the 4 hour access target was deteriorating due to the reduction in bed capacity, pathway issues in these specialties and the impact of the new rotas. (Page 31) • During September seven day working was introduced and three specialties transferred between sites. The charts show no overall changes in LoS and from the previous section in the number of discharges. (Page 130) Action by the Trust In response to the rapid deterioration of the 4 hour access target the Trust moved Elm Ward into Holly giving an extra 9 beds and has now also opened Japonica Ward’s 24 beds at King George. Beyond this and a general statement that more capacity may be needed in January/February 2014 no further action has been identified. My report back from the meeting indicates that there was little if any discussion by non-executive directors on this item. Comment It is very hard to see the logic behind the statement that the Trust needs around 100 extra beds to cope with winter pressures and the initial closure of Holly Ward. Even now with the Ward re-opened and Japonica the Trust only has a third of the required capacity. Obviously the expectation that seven day working would reduce LoS is part of the explanation for this but to put patient safety on the line for an untested change in working practice seems a very dubious decision. In fact the whole relocation exercise seems to have been a bridge too far for the Trust. Looking at the LoS graph on page 130 of the Board papers I would say the figures for August to September this year are in fact significantly higher than for 2012 and bed closures depend crucially on this reducing. Again how Holly Ward could have been closed given these data is a very real question for the BHRUT Board. All of this adds up to an escalating crisis driven by a desire to fulfil the Health4NEL strategy and the bed closures it requires. The truth is that Queen’s and King George need more not less beds. Action is needed There is an urgent need for BHRUT to identify 60-70 additional beds to see them through the winter period. The CCGs and the National Trust Development Agency should be working through the Urgent Care Board to ensure these are in place. On a longer timescale the BHRUT Board should be looking with the CCGs at how the decision to relocate services was made and how ward closures are tied in with their plans and communicated to the public. They have now published a clinical strategy to implement the Health4NEL plan but this is largely narrative and does not contain the essential linkages to ward closures, bed numbers and other metrics. Based on the current performance The Board and its partners should be reviewing the viability of the plan as well. Finally, Redbridge Council should be raising concerns both through its Executive and Health Scrutiny. It is important in this that reassuring the public is balanced by the “critical friend” approach and accurate information. As an example a recent delegation to full Council was told that the closure of Holly ward was for redecoration. This was not the full picture and led to confusion and a series of letters to the local Recorder newspaper in which I was eventually involved. There are lessons here for everyone but action to open more beds is essential now to avert the emerging crisis.