High Court says downgrade of Lewisham Hospital unlawful

The BBC reports here http://www.bbc.co.uk/news/uk-england-23518732 that the High Court has ruled the proposed downgrade of Lewisham Hospital casualty and maternity units as unlawful. Perhaps this could be helpful to keep open KGH A&E.

BHRUT aim to close KGH A&E in 2015

The Ilford Recorder reports at http://www.ilfordrecorder.co.uk/news/news/provisional_date_set_for_king_george_hospital_a_e_closure_in_2015_1_2284269

that BHRUT intend to close KGH A&E in 2015.

The original NHS plan to close the unit says at page 123 that 25% of the medical staff are to be sacked by 2015. The detail from the report is listed below.

For medical staff:

Health for north east London proposals will mean a reduction in medical staff at BHRUT but this represents no more than a 10% reduction in total medical staff in any given year: 2011/12 (Y+1)

2012/13 

(Y+2)

2013/14

(Y+3)

2014/15

(Y+4)

Overall change:

-8%

-7%

-10%

-2% 

How can patients not die if the closure is allowed to happen?

The Guardian report http://www.guardian.co.uk/society/2013/jul/17/barts-health-trust-losing-2m-week indicates cuts are likely to happen at Whipps making all the dangerous any closure of our A&E.

Both Redbridge and Waltham Forest need more medical staff, not less.

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

Can you help BBC with Queens Story

Jim Wheble of BBC London is looking to talk to people who have had a poor exeprience of Queens A&E.

Contact him at Jim.wheble@bbc.co.uk if you can help.

A&E target missed

The stats below are taken from the BHRUT website, they appear to have been published yesterday:

A&E 4 Hour treatment This is the percentage of patients who complete their care in the emergency department within 4 hours. The target figure is: 95% over the last four weeks, we achieved: 87.8% ENDs

The below is a quote from Averil Dongwoth's letter to Cllr Ryan on the Redbridge council website dated 9th May

 "In terms of plans for the year ahead...which will reduce the need for inpatient beds by approximately 60 beds"

 I hope Averil will be reviewing the plans to cut 60 beds until the A&E statistics improve.

 The plans to close KGH A&E need to be abandoned.

Decisions from 14 June Save King George Hospital Meeting

Apologies Cllrs  Ruth Clarke, Vanessa Cole,  Paul McGeary

Attendance

Bob Archer, Bill Howe Helen Zammett,  Andy Walker

BH briefed meeting about moves to reclaim monies from overseas governments whose citizens use NHS are being tightened up.

HZ very concerned about press coverage that beds at Wanstead hospital to close. If it happens is likely to put more pressure on King George Hospital (KGH) and Queens.

Following discussion on future campaigning agreed to:

a) Photo shoot outside KGH on Saturday 26 October at 1pm to mark 2nd anniversary of closure decision with a call for the KGH A&E closure plan to be dropped and maternity to return to KGH .

b) A petition calling for the return of maternity to KGH and the dropping of the closure plan plan to be presented to September full council.

c) A public meeting to be held in autumn

d) AW to pursue what evidence was provided to by Barking Havering Redbridge University Trust to Independent Reconfiguration Panel in 2011.

What's going on at BHRUT?

A local resident sent me this headline earlier today from Health Service Journal of 18 June. I could not find anything on BHRUT site about it. I phoned press department and told it was correct.  

Troubled trust avoids regulator ‘cap’ on A&E

about Queens A&E.  This lack of reporting a key issue does not appear to be the transparency demanded by the Francis report. We should find out important developments from the BHRUT direct rather than the press. BHRUT need to issue a press release on this issue ASAP. 

The latest BHRUT Chairman’s report of April this year I can find at
http://www.bhrhospitals.nhs.uk/Downloads/about/bhrut-trust-board-papers-0513.pdf says:

“4. Never Events:

We have now had three surgical never events in the past few months, fortunately

without major harm to patients, and I remain concerned that the Trust’s approach is

inadequate. It is simply not good enough for individuals, including senior clinical

colleagues, to shrug their shoulders and accept that “these things happen”.”

Suggest never events need to kept track of too as a key performance indicator on the council website.

Closing KGH A&E sacking medical staff and putting thousands more patients into Queens must increase the chances of more never events which is why the campaign to keep open our A&E must succeed.