This report will follow.
Minutes:
Mr Steve McManus and Dr William Oldfield gave a presentation of Accident & Emergency (A&E) performance at Imperial College Healthcare NHS Trust (ICHT).
Whilst there had been no increase in the total number of attendances at ICHT, there had been an increase in St. Mary’s Hospital (SMH) T1 (a consultant-led 24-hour service with full resuscitation facilities). This had been in line with the planned increase following the closure of the Hammersmith Hospital (HH) emergency unit closure.
The Charing Cross Hospital (CXH) T1 attendances had been broadly static, although there had been some variations. The figures did not reflect the patterns of attendances. There were surges in activity, particularly at SMH, where there could be a difference of 100 in attendances from one day to another. In addition, T1 activity included a greater level of category A/London Ambulance Service activity. This had become the normal level of activity.
The presentation set out: the key initiatives in place in respect of winter resilience planning; and the additional actions being taken in respect of the A&E improvement plan; and referred to the NHS review of A&E services in NW London.
In conclusion, Mr McManus stated that ICHT was not where it wanted to be, but was focusing on improvements and deploying resources to bring about these improvements.
Mr Naylor outlined his recent experience at CXH, when he had attended A&E on a Monday afternoon. The area had been full and staff overworked. Mr Naylor had been admitted to an Assessment Ward where he had overheard staff discussing how to move patients to other areas of the hospital. Mr Naylor queried what ICHT was doing to implement its promises.
Mr McManus responded that it was recognised that teams were working very hard to deliver appropriate care, and they were being supported through additional capacity in terms of beds and staff, at both SMH and CXH. It was likely that Mr Naylor had attended CXH during the outbreak of infection, when 22 beds had been closed. This infection had been contained and the beds re-opened.
Mr Naylor commented that it did not make sense to close A&E departments and close beds. Mr McManus stated that ICHT was not looking to close the CXH Emergency Department, but was waiting for national guidance on Emergency Departments. In the foreseeable future, there would be no changes or services withdrawal. Dr Oldfield added that it was not just an issue of capacity, but also staff who were able to make decisions. The six emergency consultants in place from mid-December were joint appointments between SMH and CXH.
Councillor Carlebach queried the number of patients who had received the flu vaccination. Dr Oldfield responded that patients who were thought to have flu related illnesses were asked about the vaccination, but this data was not captured.
Councillor Carlebach queried whether there was any evidence of patients with fairly serious illnesses contacting their GPs and being told to go to A&E. Dr Oldfield responded that there was no evidence. However, patients who needed primary care would be treated in the Urgent Care Centre (UCC).
Councillor Brown queried whether ICHT was learning from those trusts which were performing above target. Mr McManus responded that within NW London and London as a whole, there were a number of organisations of similar complexity with which ICHT was actively working, including Chelsea and Westminster NHS Foundation Trust. The Emergency Care Intensive Support Team provided support at a national level for trusts to learn from best practice around the country and to implement sustainable improvements.
Councillor Brown queried the percentage of patients presenting inappropriately at A&E and UCCs and what could be done both locally and from the wider NHS perspective. Dr Oldfield responded that all patients presenting at A&E and UCCs needed help. However, there was a need to signpost people to available services and to educate people to access healthcare at the right point and at the right time.
Councillor Brown suggested that the measures should have been put in place sooner and that the delays with the Northwick Park Hospital refurbishment had had significant impact. Mr McManus agreed that it would have been beneficial, but it also needed the right people to take decisions. There were interdependencies across the sector and pressures at one hospital were likely to challenge other organisations. Dr Oldfield added that there was a realisation that decisions made by senior staff resulted in shorter inpatient stays and better outcomes. ICHT was moving towards extending consultant led services, but there were insufficient consultants and also insufficient occupational therapists.
Councillor Chumnery queried: how attendances compared with previous years; whether there was a trend in respect of increase in attendances at certain times; and for how long the additional actions had been in place.
Mr McManus responded that there had been an increase in attendances of 0.7% over the previous 2/3 years. A further increase to 0.8% was forecast to the end of March. In addition, there had been some changes in terms volatility and acuteness. It was believed that there had been larger increases in activity across the country. ICHT had taken a pro-active approach in respect of known seasonal trends. The presentation set out the key initiatives in respect of winter planning, including additional beds.
Dr Oldfield added that there had been a change in the hours senior doctors worked and an increase in ward rounds. Patients on the medical acute unit were seen on a daily basis. In addition there had been improved diagnostic facilities, changes in treatment and huge changes in work practices. A combined discharge team including social workers, housing and health supported people back into the community. ICHT liaised on a daily basis with the lead commissioner to discharge people into more appropriate settings.
Mr McVeigh queried if there were any aspects of the relationship with the Council which could be improved. Mr McManus identified two aspects: a single discharge team instead of three separate teams; and pro-active discharge of patients into a safe location for on-going assessment.
Councillor Lukey stated that the Council appreciated the hard work of NHS staff and of Adult Social Care on a seven day basis, and particularly around hospital discharge. There was the basis of good joint work
Councillor Lukey stated that the Council had previously been told that it was not possible to recruit additional clinicians and therefore the number of A&E departments had to be reduced. Councillor Lukey noted the impact on bed usage and queried where local patients who went to CXH A&E were transferred.
Dr Oldfield responded that to ensure the consistency of senior decision makers, there would be consultants on site from 8am to 10pm and then consultants on call from home. The Trauma Centre at SMH would have consultants on site throughout the night. Mr McManus added that ICHT was actively increasing the length of time in the day during which consultants were available on site. An additional six emergency consultants had been in place from mid-December. It was intended to further increase the hours to midnight from April 2015, and expand cover across a seven day week.
Dr Oldfield stated that patients were regularly transferred because of clinical needs, for example to the Cardiac Centre at Hammersmith Hospital and to CXH for specialist neurology. Councillor Lukey queried whether patients were moved to other hospitals because of bed shortages. Dr Oldfield responded that, whilst it might be necessary to move patients because of bed capacity, they would not be moved out of the ICHT group.
Councillor Fennimore stated that the Council had been told that there would be no impact on capacity from the closure of Hammersmith Hospital A&E, and queried whether closure at that time had been a mistake.
Mr McManus responded that the year to date (18 January 2015) performance figures for four hours waiting time showed 94.1% against the target of 95% and 94% nationally. It was believed that the measures put in place had been sufficient. The target had just been missed because of seasonal fluctuations. ICHT had increased medical beds and moved senior decision making staff from HH to CXH and SMH.
ICHT would still have wanted to close HH A&E, as it was not safe. It had not been run by emergency consultants and could not provide safe emergency care. In respect of the timing of the closure, there was no right time to close facilities. The unit had been struggling to recruit senior and junior medical staff. It was not designated as an A&E unit and therefore working at the unit was not a substantive career appointment for junior doctors. The unit had been staffed by acute medical consultants. There had been no out of hours consultant cover and junior doctors were employed from agencies. The level of activity transferred from HH was in line with that planned. The increased activity was a national situation, not just North West London.
Councillor Cowan queried whether ICHT had been surprised and disappointed at the CQC rating of SMH A&E. Mr McManus responded in the affirmative. An action plan would be taken to the Trust Board the following week, and ICHT would be attending the February PAC.
Councillor Cowan queried ICHT’s preparation for the inspection, and specifically briefings of doctors and other staff engaged in medical activity. Mr McManus confirmed that ICHT had organised mock inspection visits. Each of the clinical services had undertaken a self assessment of the five domains of quality. The mock visits had been peer reviewed, looking at the different domains and there had been extensive briefings on what would be involved. Staff had been encouraged to speak openly and honestly and to engage with the CQC.
Councillor Cowan queried what ICHT had learnt from the CQC report. Mr McManus responded that ICHT had learnt some positive things about its care and services, but there had been issues in respect of cleanliness at SMH A&E These had been acted upon immediately and the required improvements put in place. There had been a re-inspection in November and the report had been re-issued with the re-inspection findings.
Councillor Cowan suggested that there were wider issues in respect to the quality of the plan around CXH, when fundamental problems had not been spotted. Mr McManus responded that managers were leading a complex system and there were significant forward plans. There had been recent changes to the leadership and ICHT was now in a stable position. There had been a significant endorsement of the plans, particularly in respect of the way forward.
Councillor Cowan referred to the financial alarm in September and suggested that a consultant should be engaged and the issues raised put right rapidly. Mr McManus responded that the financial pressures were significant across the country and that ICHT was actively working to keep finance on track, together with quality.
Councillor Cowan queried whether the CQC report had led ICHT to question any aspect of its resource planning. Mr McManus responded that as part of the CQC Action Plan, ICHT had reviewed how it had got those issues wrong and planned to learn from the report.
Councillor Cowan queried whether ICHT had withdrawn its bid to become a foundation trust. Mr McManus responded that ICHT could not proceed with its foundation trust bid until it was rated by the CQC as ‘good’ or better. The challenges across the country in the emergency pathway were reflected in NW London.
Mr Andrew Slaughter, MP, queried whether it had been sensible to close HH at that time and the impact on CXH. Mr McManus responded that CXH was relatively static. The movement of HH patients to CXH was not anticipated. There had been a significant increase due to the winter period. The T1 patient category could not be correlated with HH. There had been a step change in activity figures from HH to SMH.
Mr Slaughter queried the drop in A&E performance T1 to 65/70% and whether the postcodes of CXH attendees had been analysed to find out if the additional workload was commensurate with the closures. Mr McManus responded that post HH closure, the volatility of attendances had been up to 100 on different days, commensurate with winter pressures. There had been an increase in category A, covering particularly acute cases. This was regarded as the new norm, with which ICHT would have to cope and manage capacity.
Dr Oldfield commended the hard working staff at ICHT and noted ICHT’s achievement as the fourth best performing trust in respect of mortality. Councillor Cowan responded that the Council also commended the staff, but had concerns about the quality of management and the significant failures.
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