Reducing our waiting lists
“Works for staff. Works for patients. Works for the taxpayer. Impressive!” This was the judgment of Chris Hopson, NHS England’s Chief Strategy Officer, after he spent time at our Elective Surgical Hub at King George Hospital (KGH). Another visitor who left impressed by what he had seen was NHS England’s Chief Operating Officer, Sir David Sloman, who spoke of how our Trust was doing some “brilliantly innovative things”.
There is, rightly, a focus on what is being done to reduce the length of time people are waiting to receive treatment. In this context, the KGH hub is a real asset and we’re the only trust in London – and one of eight in England - to be going through a process of receiving national accreditation for the work being carried out there.
The Elective Surgical Hub at KGH concentrates on six specialities which make up 70 per cent of our waiting lists – general surgery, ear, nose and throat, trauma and orthopaedics, ophthalmology, urology, and gynaecology. This hospital within a hospital contains wards, theatres (with more being built) and a critical care unit which has been designed to ensure planned operations aren’t cancelled because of emergencies. Its success is down to the team spirit that’s been encouraged and the shared desire to learn, adapt and innovate.
We’re the first trust in the country to use a robotic colonoscopy machine that has the potential to transform such tests; we’re training the surgeons of tomorrow in the use of our robots, having passed the milestone of our 100th robotic joint replacement; and our Urology department is using a new kidney stone machine that is allowing them to treat five times more patients each week.
All of this work is having a positive impact on the number of people on our waiting list, the vast majority of whom need to be seen in outpatients. The total was 61,219 in January, a reduction of more than 4,500 over recent months. This is no mean achievement given the demand for our services, post pandemic, continues to increase.
We are doing some pioneering work with those who have a learning disability to ensure their visit to hospital is supported by our learning disability team so that they are prepared for their appointment and have the correct care and support in place when they are seen. We know that when this doesn’t happen, the patient and their family often have a poor experience.
Waiting is stressful, especially if it is for the result of tests for suspected cancer. When an operation is required, we have a prehab cancer team who see some of these patients and the feedback from one of them, Kathleen Rutter was particularly powerful. Aged 79, Kathleen told us the team had made her feel that she was “worth saving and it was worth fighting for”.
To help hospitals ensure waiting lists are reduced, NHS England have set targets to be achieved over the coming years. By the end of this month (March 2023), we are expected to have eliminated waits of more than 18 months (78 weeks). It is a challenging target for us to deliver – we had 47 patients in this category in February - but we are determined to do it.
We have made very impressive progress reducing to 1,372 (by January) the number of people waiting more than a year. We have an ambitious plan to cut this to zero over the next six months, more than a year ahead of the 52-week target set by NHS England.
Our collaboration with Barts Health
For the collaboration to be judged a success, the two trusts have set a simple test – it has to deliver real benefits to patients. This also applies to the work we’re doing with Barts and Homerton Healthcare. Recent examples of our collaboration include the first joint revision knee surgery that took place when our surgeons joined forces.
A pioneering scheme to help more people avoid long A&E waits is being extended from the Royal London Hospital to our Trust. The Remote Emergency Access Coordination Hub (REACH) involves hospital consultants giving specialist advice to paramedics so people get the most suitable treatment as quickly as possible, including being kept away from a busy hospital. The expectation is that once it is fully up and running, around 25 people a day won’t need to come to our A&Es because they’ll receive treatment in a better environment.
Care Quality Commission
The use of REACH is just one of the ways we will address the issues raised by the Care Quality Commission (CQC) when they inspected our A&Es and other services in November last year. Their report has now been published and it is a fair one.
We share their concern about the fact that, like many other hospitals across the country, we have had to look after some patients on hospital beds in corridors. When we invited BBC London to film the impact this was having on patients and staff in the A&E at Queen’s Hospital, we made clear that the care we sometimes provide isn’t what we’d want for our own relatives.
The CQC report, which I’d recommend you read in full, praises our staff for treating patients with compassion and kindness. The CQC also found that our work to build stability into the leadership team, and develop a model of inclusive leadership, was “beginning to positively impact the culture across the organisation”.
The inspectors highlight something I have drawn attention to repeatedly in my CEO Board report - the number of mental health patients we have waiting for long periods of time in A&E cubicles because of a national shortage of mental health beds. They described it as a “significant issue of concern”.
In January, we had 335 such patients. The average length of stay was 20 hours. 38 of them waited more than 36 hours to leave our Trust and move to a service better able to care for their needs.
In their report, the CQC accept that the issues they’ve highlighted at our Trust are made worse by financial and service pressures in primary care, adult social care and community care within the wider system.
To address this – and the persistent problem of too many A&E patients with mental health needs waiting too long for the right care – the CQC organised a quality summit to look at ways in which all healthcare providers in north east London (NEL) could work together to improve the provision of urgent and emergency care at our two hospitals. I’ve attached to this report the notes from that meeting at the end of last year.
Urgent and emergency care
While we welcome the support of our partners in NEL to improve the experience of patients using our A&Es, we know there are things we can put right as a trust. We are increasing the size of the Same Day Emergency Care (SDEC) department at Queen’s where people are seen and treated on the same day so they don’t have to be admitted; the number of patients leaving wards before noon each day is increasing (there was a 35% increase in January compared to the same time last year); and our drive to actively move patients out of A&E and onto wards has seen a rise of more than 20 per cent in the number being transferred.
This ongoing work is beginning to deliver results. Our Type 1 performance at Queen’s (treating those patients with life threatening injuries or illness) was up 10% in January, compared with the year before.
We’ve done some initial analysis of the impact of the recent ambulance strikes. We found that on each of the four strike days there was a reduction in ambulance activity of up to 30%; there was no fall in the number of people arriving in A&E via their own transport or from the Urgent Treatment Centres; and on three of the four days, the number of patients aged over 75 being brought in by ambulance went down.
We are changing the way we run our hospitals to improve the experience of our staff and our patients. A recurring problem has been our failure to deliver, day in day out, the smooth and continuous movement of patients out of A&E, through the hospitals and back into the community.
To improve what the NHS calls “flow” we’ve introduced site-based leadership at the hospitals and appointed Louise Dark from NHS London as KGH’s Managing Director. The two site teams will be responsible for the day to day running while five Clinical Groups (replacing seven divisions) will be more forward looking, concentrating on strategy, workforce recruitment and retention and quality and safety. To help us deliver this transformation, we’re recruiting three Directors of Operations.
The successful candidates will be compassionate and inclusive leaders who will respond promptly and correctly when a colleague complains about their treatment at work. One of the things that irritates some staff is the length of time a disciplinary process can take and the limited information that is provided about the outcome. We were pleased that last month an Employment Tribunal threw out a claim for unfair dismissal by one of our former senior doctors after we sacked him for sexual harassment.
We remain on track to deliver a deficit of £15m by the end of this month which is also the end of the financial year. From May, we plan to no longer pay for any high-cost agency nurses (known as off framework). The rates charged are unfair - sometimes the cost of the individual is three times more than that of a permanent member of staff they are working alongside - and unaffordable; as one of my colleagues put it, we need to stop “burning a hole in our wallet”.
We rely on these nurses most often in A&E and critical care. We've increased the bank rates for nurses in these specialist areas by around 25%, in line with what is on offer at Barts Health. We are starting to see an increase in the number of bank shifts being taken up by colleagues.
We will also fill the gaps by recruiting around 80 student nurses (who will start work in the autumn) and nearly 200 qualified nurses from other countries. Their arrival, over the next nine months, is a reminder of the vital role international staff play in the NHS.
We will continue to work to be an attractive local employer and provide access to jobs for the residents of our three boroughs. Several nurse associates have recently become registered nurses and a further 22 will qualify next year.
The coming months
As well as improving services at our sites, we’re always looking at ways of bringing care closer to where people live. We’re pleased Barking and Dagenham councillors have backed our plans to provide more tests and scans at a new community diagnostic centre at Barking Community Hospital. We are also considering what services to move out of the hospitals into the new health and wellbeing hub that is being built on the site of the old St George’s Hospital in Hornchurch. It will open in March 2024.
At the time of writing this report, junior doctors were planning a 72-hour walkout. If their strike goes ahead in March, it is likely to have a significant impact on our services and result in the cancellation of appointments and operations, so that we can deliver safe care with a reduced workforce.
Outer North East London Urgent & Emergency Care Pathway
20th December 2022
Room 5.10s Franklin, 5th Floor, Wellington House, London, SE1 8UG
Chair: Andrew Ridley, Regional Director, NHS England - London
|Care Quality Commission (CQC)||North East London ICB (NEL ICB)|
|Barking Havering and Redbridge University NHS Trust (BHRUT)||NHS England (NHSE)|
|Partnership of East London Co-operatives (PELC)||London Borough of Havering (LBH)|
|North East London NHS Foundation Trust (NELFT)||The Barts Group|
1. Welcome, apologies and introduction
The Chair welcomed the attendees to the meeting. AR set out that the main purposes of the meeting were to explore the recent CQC findings regarding the Outer North East London Urgent & Emergency Care Pathway and to support a whole system response in order to make improvements.
2. Scene setting and findings of CQC visits
The CQC set out the background to the inspection. This inspection was to follow up on the previous inspection of UEC at Queen’s Hospital and local UTCs run by PELC in November 2021. This was conducted as part of the CQC system wide review of UEC across the North East London integrated care system.
The CQC identified issues with flow, in and through the emergency pathway, and had significant concerns regarding the impact of this on safety and quality of care.
The CQC found that the challenges BHRUT faced were complicated by wider challenges within the health and social care system. A Letter of Serious Concern was sent to the Trust, requesting both a Trust and wider health and social care system action plan to address the concerns..
The CQC set out the inspection findings. The CQC found concerns about patient safety between arrival and streaming. There was a failure to meet a 15-minute streaming target, particularly at the co-located sites. The CQC reported that between September and October 2022 more than 50% of patients were waiting over 45 minutes to be streamed, and in October 2022, 33% of patients were waiting more than 2 hours to be streamed.
There was also a failure to record patient arrival times at certain PELC sites and as a result the safety and performance of the department, could not be monitored. There was a lack of effective monitoring of patients in the waiting areas at any PELC site.
The CQC found concerns over the time, resource intensity and accuracy of handing over to the BHRUT emergency department. The incompatibility of the record systems between the co-located UEC and Eds, added to the challenges.
The CQC found concerns over the capacity to learn from significant events. Handover delays were not routinely being logged on Datix. At the time of inspection more than 80 of the significant events which had been logged were still awaiting review. The CQC had found similar numbers awaiting review last year.
The CQC found concerns about gaps in the staffing rota and identified recent staffing deficits against the rotas of at least 10% for doctors and at least 20% for nurses.
The CQC found significant concerns about the flow into and out of the emergency department to function effectively to keep length of stays within the emergency department at safe levels. This led to subsequent overcrowding and excessive demand on staff.
At Queen’s Hospital, the CQC saw patients on ambulance stretchers and hospital beds waiting in the main corridor for an extended time and in full view of other staff and members of the public. The process in place for offloading ambulance patients did not allow for crews to be released back to the road in a timely fashion.
The CQC found multiple IT systems being used within the department at King George Hospital (KGH). This risked deteriorating patients not being identified in a timely manner, and various risks to the safe administration of medications.
The CQC found that delays in transferring patients with mental health needs was having a significant impact on the capacity of the emergency departments (ED) at BHRUT to treat patients in a timely and effective way. The large numbers of ED cubicles being used for MH patients equated to the loss of capacity for 30 physical health patients a day.
The CQC found a bottle neck when discharging patients out of the hospital into adult social care. Delays were also exacerbated by adult social care providers in the community not being accessible on weekday evenings or over the weekend.
Delayed discharge data at Queen’s Hospital, showed that on average 20 discharges of medically fit patients a day were being delayed and that the main cause was waits for adult social care, followed by waits for short-term rehabilitation beds in the community.
JR noted that these issues were not unique to the trust. JR set out how the CQC had hoped that issues from previous inspections would have been addressed. Letters of concern and enforcement actions had been issued to providers, but the CQC was now looking to the wider system to help address the issues.
AT responded that he considered that the CQC assessment of the challenges was fair and that the trust recognised the issues identified.
3. Overview of wider system challenges
NEL ICB representatives set out some local background to the challenges faced by the system. BHRUT is one of the busiest A&Es in the country and within Barking and Dagenham, Havering & Redbridge (BHR) there were significant areas of deprivation. A key factor was the growing population that was had increasing populations of both older and younger residents. There were also lower numbers of GPs for BHR residents when compared to the North East London average and significantly lower when compared nationally.
Actions undertaken by the system to respond to the CQC’s findings included: support to and assurance of PELC’s improvement plan; a new assurance board that brought together system partners including ICB CNO, BHRUT and NELFT, and reporting to the ICBs quality committee; and proposing an independent governance review of PELC to ensure its structures were appropriate and robust to ensure sustainable improvement.
Other system wide actions included: significant system work on reducing long waits for those in mental health crisis in emergency departments, including a plan recently submitted to NHS London, and a summit of all trust Chief Executives on 19 December; increasingly robust system governance on the urgent and emergency care pathway including a UEC delivery board meeting chaired by the Chief Medical Officer; weekly system resilience meeting for winter across the BHRUT footprint; work to improve primary care capacity; and work at place (Borough) level to tackle drivers of ED attendances and admissions and ensure effective discharge.
Response from PELC
SR set out some further detail and context to the CQC PELC inspection. The CQC had raised concerns about patient safety in the waiting areas, notably at Queen’s. This was a very challenging space with no clinical oversight of the queue and waiting area. There were frequent delays to the 15-minute standard for initial clinical assessment not being met. The wait for the initial clinical assessment was not being routinely reported. SR talked the meeting through the pre-existing front door pathway.
SR set out actions to reduce patient safety risk in the queues already underway since the inspection. The post of Clinical Oversight Co-ordinator had been introduced at Queen’s UTC to monitor waiting areas for obviously unwell and deteriorating patients. When this post was not present, other staff would observe the waiting area for obviously unwell or deteriorating patients and staff would also undertake this at KGH, Barking and Harold Wood UTCs. Registration processes had been changed on all sites to allow accurate monitoring of the time to initial clinical assessment. The time to initial clinical assessment was reported to and discussed at daily operational huddles.
SR set out the changes made in order to meet the 15-minute standard for initial clinical assessment. This included: partial registration at the front door; full registration at the concierge; rapid streaming; red flagged patients would receive a rapid assessment from a senior clinician and prompt referral to ED if necessary; and other minor injury or illness pathways were in place to the UTC.
SR set out the four measures that had been introduced: 15-minute initial clinical assessment target; time to rapid assessment; time to onward referral to ED/ same day emergency care; and reduction in harm and incidents reported. Initial outcomes to these measures showed that approximately 80% of patients were receiving their initial clinical assessment within 15 minutes, with significant improvements at Queens and KGH.
SR set out that they were looking to utilise a GP at the front door to further improve initial assessment. PELC would be keeping the post of Clinical Oversight Co-ordinator. PELC were working with Havering & Redbridge Borough Partnerships to put services on different sites.
Response from BHRUT
MT set out some of the actions underway to address the CQC findings. This included: enhanced support for ED teams with senior leadership presence and subject matter experts in the departments; and weekly quality of care audits being undertaken. The lack of electronic patient record presented a particular challenge, but MT noted there was a commitment from NHSE to help address this.
MT reported that CASCARD was fit for purpose, but staff required support and training to use consistently. The corridor that is used for patients, is now closed to all but essential staff to help preserve patient privacy & dignity. The trust considered that it was better for patients to wait in the corridor than wait in the ambulance.
MT set out actions to decongest the ED. Phase 1 of Operation Snowball had seen the introduction of the Frailty Pathway which had resulted in a 21% increase in patients transferred. Phase 2 had seen the introduction to medical pathways, resulting in a 25% increase in patients transferred. There had been a significant increase in discharges before 12 noon and ambulance handover times had also improved significantly.
MT set out some of the challenges caring for mental health (MH) patients in the department. Average length of stay (LOS) for MH patients in the ED (from when they had first been referred to MH services) had risen significantly and the average for November was 20 hours. There were 40 patients that spent in excess of 36 hours and one patient with Learning Difficulties had spent over 200 hours in the department. MT noted the need for system solutions to help address this.
MT set out how there were typically 130-140 patients declared medically fit for discharge each day. A snapshot external delay audit was also shown. MT set out the key areas of delay. This included: packages of Care confirmation timeframes; sourcing and acceptance for nursing home placements; family choice of placements; and delivery of equipment.
Response from NELFT
JVR gave the meeting some context to the mental health pathway in NE London. There was a high bed utilisation over the last 6 months which was not abating, and there were high numbers of out of area patients. There were London wide increases in the use of section.136, impacting on detainments in ED as a place of safety.
Overall MH presentations to ED remained fairly static, but with increasing general attendances, the length of time in the department had increased, with 12 hour waits more frequent. Two factors were linked to this: process in the department & reporting; and increased acuity and complexity of presentation. Issues with patients waiting more than 12 hours at KGH and Queens were particularly acute due to challenges which included: waits for bed; waits for Mental Health Act Assessments; and waits for social care placement or placement breakdowns.
JVP noted that patients waiting in ED for long periods was unacceptable, with potential adverse impacts on patient experience and outcomes.
JVP presented graphs showing current performance. NELFT had one of the lowest length of stay rates in London, but the demand in the pathway led to high bed occupancy which can impact on flow out of the ED. The focus for the trust was to work with communities and partners via transformation programmes to coproduce solutions that were effective and timely. Key areas for impact were: crisis support and diversion; ED process and support; data and escalation; and bed capacity & flow.
JVP set out the principle elements of each of the key areas for impact including: the establishment of the Integrated Crisis Assessment Hub in NELFT; the establishment of a Mental Health Joint Response Car in partnership with LAS; UTC front door Band 7 MH support; 24/7 ITC MH support; live 30 minute refresh data feed of activity in the ED department; commissioning additional local private sector capacity to support flow over winter (targeted at out of area patients specifically); and working in partnership to develop the enhanced MH annex in ED (scheduled for February 2023).
JVP set out the expected outcomes of these initiatives. This included increased UTC/ED avoidance; improved conveyance diversion from ED to MH crisis hub; improved access to MH at point of walk in entry to UTC to divert away from ED; rapid access to IAPT triage; improved links to social care; and reduced ED average length of stay, for all patients presenting as MH with better diversion to correct pathway and a reduced number of 12 hour breaches.
Response from the Barts Health group
SD set out how Barts & BHRUT had a joint Chair in common (JS) to aid integration at Board level between the two trusts. This arrangement facilitated learning from both organisations, and they were also working together in the broader acute collaborative. SD set out how the collaboration supported delivery of ICS goals and the collaborative plans. The plan for UEC had 6 priority workstreams and these were shown to the meeting. This included extending the REACH service, whose purpose was to improve equity of access to non-elective care for the population of NEL and reduce ED admissions. A joint workforce team will be established, hosted at Royal London Hospital, to deliver the REACH services across BHRUT for winter.
Dr Karim Ahmed (KA) had been seconded from Barts to BHRUT as clinical lead for UEC.
KA informed the meeting that the partnership was developing an integrated, unified model that was trying to do things differently.
Actions from wider local system
ABH, CEO for the London Borough of Havering, informed the meeting that in addition to the slides presented to the meeting, he would be giving additional information that focused on Urgent care and admission avoidance across the BHR footprint.
ABH acknowledged the changing nature of the BHR population and the growing child population. ABH set out that the boroughs were focusing on admissions avoidance, with the need to focus on prevention, to stay at home and not in hospital. The boroughs had developed programs to help support residents through the cost of living crisis. The boroughs were also focusing on 7-day discharge, with discharge services across BHR delivering 8am to 8pm, 7 days a week. There was a focus on improving delayed transfers of care for the elderly and frail.
ABH set out various challenges including: the low pay for care home workers and how they were leaving work in the area; and the difficulties in finding provision for children with complex needs.
The role of primary care in supporting the system
PG set out that the local primary care workforce had responded well to the challenges. PG highlighted: that there was enhanced access to GPs; GP Access hubs were in place; weekly multi-disciplinary team ward rounds were underway; care coordinators were monitoring high risk patients; and acute respiratory hubs had been developed. PG considered that the full capacity of nursing was not being used but there had been improved communications on how to access primary care through social media and improve the efficiency of access to what is already on offer.
JS noted how seriously the trust Boards were taking the issues. Operation Snowball was beginning to make a difference. JS noted: the impact of REACH; the challenge of the lack of digital capacity; how the joint NEDs had helped facilitate a joint approach; that there had been significant investments in the environment of the Eds, especially KGH, and now the focus was on Queen’s Hospital; the impact on the under provision of primary care on the trust; and that social care funding remained enormously challenging.
4. Discussion to:
• Agree actions and support to address key risks
• Agree next steps
AR noted the quantum of the primary care challenge and asked what the ICB plans were to increase capacity. ZA responded that an Integrated Delivery Framework was in place to deliver to an expanding population and a local Infrastructure Forum was in place in each borough.
It was reported that discussions were underway with Queen Mary University to establish an Academic Centre at BHRUT which would help attract clinicians.
AR asked if there was a capital plan. ZA responded that a borough-by-borough piece of work was underway.
Various challenges were discussed including: the retirement of elderly GPs in Havering; recruitment & retention; key worker housing; the cost of travel for low paid health workers travelling into the boroughs; the population growth; the lack of capital; the challenges of employment in social care; and the cost of living.
MT set out that it was very risky for NHS trusts to buy care homes but that the trust was looking to work in partnerships with care home providers. This would have the value of having the NHS badge as a recruiter. MT also set out how BHRUT was looking to locate more geriatricians in the community.
ZE questioned what a different model of care would look like for young people with MH issues. ABH noted that the council can own buildings but needed the providers to provide the care.
CS noted the bravery of the clinicians who took on medical leadership roles to help address the UEC challenges, that support was needed for them, and that the leadership tier below needed to be brought forward. CS noted the need for frailty specialists to support General Practice. CS also recognised the leadership challenges in addressing poor practice/medical development. CS offered to hold a conversation with other NHSE London medical leadership colleagues about how more support can be offered.
Action 1. Chris Streather to develop medical leadership support for medical leaders in urgent & emergency care at organisations across the system.
MT noted the high cost of agency medical staff and that they were not as engaged in service development as permanent medical staff. MT noted that BHRUT, as a consequence of the high deprivation in the area, gave great pathology experience to medical staff. CS had been providing support to the BHRUT Medical Director.
SR noted that PELC had also had some issues regarding the productivity of some GPs.
A discussion was held about mental health provision. AR asked if there were enough beds in the system. JVR responded that there had been low bed numbers for 10-12 years. There was double the case load and pressure through the whole pathway. AR asked what bed base was needed now. JVR responded that this was currently being reviewed and this would report in March and planning would follow. Buildings were needed. Female beds were often difficult to find.
JR asked what outcome measures organisations were using. JR said that the CQC would align their regulatory process around those measures. MT offered to share the outcomes of transformation programmes and that he could also share data around inequity and access issues.
MT noted that workers on zero hours contracts would often wait for many hours in UEC, as this was the only option for them to get treatment due to their working arrangements. A number of initiatives and action plans were under development to address the complex challenges. To enable the CQC to draw on the outcome measures as part of their support/inspection response the ICB offered, where possible, to draw together key outcome measures into one document
JVR reported that NELFT were remodelling their bed days and expected this to impact on length of stay. ZE noted the complexity of this piece of work. To know if MH flow was working properly, the right set of outcome measures were needed. MG stated that the trust was putting together key success indicators.
Action 2 – NEL ICB to draw together the outcome measures and outputs, relating to the discussion today, which will describe what success looks like. These will be shared.
Action 3 – The CQC will draw on the outcome measures identified by the system to align their approach for targeted visits and follow up meetings.
The Chair asked if there were any other issues anybody at the meeting wanted to bring to the discussion. There were no other issues.
5. Concluding remarks
The Chair thanked participants for their contributions to some very interesting discussions. AR noted the difficult circumstances but noted the high level of partnership working and commended the efforts of the whole system to find solutions to the challenges.