We’ve all been horrified by the Letby trial. In the words of the judge, Mr Justice Goss, she acted “in a way that was completely contrary to the normal human instincts of nurturing and caring for babies and in gross breach of the trust that all citizens place in those who work in the medical and caring professions." Our thoughts are with the families who’ve been devastated by these murders and attempted murders and with the many staff at the Countess of Chester Hospital who did their very best for the infants and their relatives.
The trial established Letby’s guilt. The public inquiry will look at the lessons the NHS can learn from her crimes. Amanda Pritchard, CEO of NHS England, has written to all senior leaders to remind them of their obligations under the Fit and Proper Person requirements and to remind staff of all the ways they can speak up when they have concerns about safety. At our Trust these include our Guardian Service. It is an independent, non-NHS body that has helped 385 colleagues over the past three years. The increase in the number of cases they respond to shows the culture around feeling free to speak up is improving at our Trust.
We are continuing the work to cut the deficit – which now stands at £15.9m (year to date) - in ways that aren’t detrimental to quality and safety. Our focus is on reducing waste and expenditure in areas where it isn’t necessary. We are still spending too much money on agency workers rather than using our Bank staff and the total headcount remains too high. One factor that is outside of our control is the £1.7m adverse impact of inflation.
Strikes by doctors
The cost of the industrial action by junior and senior doctors – including lost income due to reduced clinical activity - was £4m to the end of July. As well as this, the strikes are affecting morale and run the risk of creating division between different clinical groups. The junior doctors I have spoken to feel that the government doesn’t care about them. I have sympathy for their concerns over pay and conditions. They are the future of the NHS and like many others I am desperate to see proper negotiations getting underway. The status quo is increasingly untenable, especially for our patients. So far, we’ve cancelled 10,055 outpatient appointments and 721 non urgent surgeries.
Cutting our waiting lists
These cancellations – and the planned strikes by junior and senior doctors over the next two months – mean we are no longer on track to fulfil our pledge to reduce to zero, by the end of December, the number of people waiting more than a year for their treatment. There were 1,429 patients waiting this long at the end of July. In total, we have 65,493 people seeking treatment, the majority of whom need an outpatient appointment. We have seen a five per cent increase in referrals this year.
Our clinical teams are continuing their drive to reduce their waiting lists and the TonKIDZ initiative has cut by a quarter the number of children waiting to have their tonsils removed.
The service for those needing diagnostic tests will be improved – along with waiting times for diagnosis - once we’ve opened a Community Diagnostic Centre (CDC) at Barking Community Hospital. The CDC will be ready next year and the new facility is progressing well.
Urgent and emergency care
During the visit, I was able to show their reporter what I described as the “green shoots” of recovery in our urgent and emergency care. In July we improved our Type 1 performance against the national target by more than 20 per cent, compared with the same month last year. The national standard is 95 per cent; a recovery target of 76 per cent has been set with the expectation it will be hit by March 2024.
At Queen’s Hospital, this was the first time our Type 1 performance has been above 50 per cent since October 2019 (excluding Covid-19 lockdowns). For the most seriously ill patients, we have moved from being the worst performing trust in the country to being above 19 others and we are no longer bottom of the table in London.
I know we have much more to do and I am sorry that too many people are still waiting too long. The national recovery target of 76 per cent is for all our patients. Roughly half are seen in the Urgent Treatment Centres (UTC) that are run by PELC, a GP cooperative.
For us to achieve 76 per cent by March next year we need the UTCs (where the less seriously ill Type 3 patients are treated) to achieve greater than 90 per cent performance. In July it was 70.9% (PELC is one of 11 providers with performance below 90 per cent).
We have a good working relationship with our PELC colleagues and we’re exploring how we can share our diagnostic services and some of our staff to help with the treatment of minor injuries.
Our Type 1 improvement has been achieved thanks to the hard work of our teams in A&E and across the hospitals; an improvement in our operational leadership; and the opening of Same Day Emergency Care (SDEC) departments at both sites. It’s where patients are moved out of A&E to be assessed and have treatment (including diagnostics) start on that same day.
Our SDECs are seeing an average of 116 people a day; there was a decrease in the number of those waiting more than 12 hours from 2,375 to 1,872 between June and July; and the number of patients spending more than 36 hours in A&E reduced from 270 to 176 in the same period.
A key factor in reducing A&E waits is improving what the NHS calls flow – the smooth and continuous movement of patients out of the department, onto the wards and back to their homes. This is being helped by our new, bedded discharge lounge at Queen’s. We’ve almost doubled the number of patients who are now being moved here, from the wards, while they wait to leave hospital.
Another of our successes is the initiative we’re part of with the London Ambulance Service to ensure they hand over patients to us within 45 minutes of arrival. The north east London pilot has resulted in a significant reduction in the length of time these handovers take at the Trust.
Preparing for winter
NHS England have published their approach to winter planning and our challenge will be to sustain the improvements we’ve made. We plan to open a ‘virtual ward’ this month that will provide much needed additional clinical support to keep frail and elderly patients at home, rather than have them admitted to hospital.
We are working with partners to establish what’s also known as a ‘hospital at home’ service. A multi-disciplinary team will deliver care in the community, not in hospital, which is better for the patients and will free up beds during the winter months. It has the potential to transform acute services and help our most vulnerable patients avoid spending time on a ward.
We’ve also received £3m government funding to create a Surgical Assessment Unit with space for eleven patients who come to A&E needing surgery. We plan to open it in December and it will reduce waits and improve access to emergency surgery.
Patients with mental health needs
This is an issue of great concern that I have written about in my Board reports for more than a year. In July we saw the highest ever number of patients referred to mental health services via our A&Es – 413, 244 of whom were at KGH. The average length of stay in the departments was 22 hours. Seventy of these patients (up from 59 in June) waited more than 36 hours to leave our Trust and move to a service better equipped to look after them. While we are caring for them we lose, on a daily basis, the use of several A&E cubicles that are also needed for other patients.
We are working with colleagues at NELFT, our local mental health and community trust and I have invited Paul Calaminus, their new CEO, to KGH so he can see the problem first hand.
I am very concerned about the significant risk some of these patients pose to themselves and others while we look after them for long periods of time in an environment that is just not suited to their needs.
The improvements I’ve written about have helped create a buzz around the Trust. There is no silver bullet and it will take time for them to become sustained, and not just a blip.
In my first two years I have established a stable group of senior leaders, changed the structure of the organisation and improved the quality of our operational leadership. We’ve also introduced an innovative Shadow Exec that provides a forum for more junior members of staff to influence decision making. It’s been described by one participant as “expectation shattering”.
We continue to be mindful of the impact of the cost of living crisis on colleagues and it was good that BBC London wanted to come and learn about the work we’re doing providing school uniforms for those families that need them.
We should never underestimate the mental and physical exhaustion the pandemic inflicted, so it was great to celebrate NHS 75 with 5,500 staff members and their families. We laid on a breakfast, lunch, afternoon tea, evening party and family fun day. If you haven’t already, please do watch some of the videos. They capture the joy and the fun of a memorable few days in July.