Chief Executive’s Report May 2023
Reducing our waiting lists
There is understandable and growing public disquiet about ongoing delays to treatment which have been exacerbated by the pandemic. It is a source of pride for our organisation that by the end of March we had reduced to zero the number of people waiting more than a year and a half to be seen. We are one of only three trusts in London to have achieved this NHS England target and our success is yet another example of what can be achieved with the right clinical leadership and with teams and departments working together towards a common goal. It is good for residents, for staff morale and for our reputation as a healthcare provider serving Barking and Dagenham, Havering and Redbridge.
I’ve written before about our unremitting focus on reducing backlogs and I was pleased to speak about our approach at a recent HSJ Provider Summit. For example, last month we contacted in advance those who were booked in for surgery. This direct approach resulted in a large reduction in the number of cancelled operations because we ensured patients were well prepared and ready to attend hospital for their treatment.
This desire to improve services is evident across our Trust. Our Medical Photography team won a You Made a Difference Award for their help tackling a growing backlog of patients with urgent skin cancer referrals. They arranged 480 photography sessions during a two-month period and our Dermatology team set up a telephone triage clinic to make sure patients remained safe while they waited to see a specialist. In October last year there were more than 900 people waiting for an urgent, two week wait appointment. Three months later, we had reduced this to zero and everyone had been seen and treated if necessary.
Our Elective Surgical Hub at King George Hospital (KGH) is vital to our ongoing success as a leader in elective (planned care) recovery. This ‘hospital within a hospital’ is one of just eight in the country to have received national accreditation. The KGH hub concentrates on providing surgical care for six specialities that make up 70 per cent of our waiting lists – general surgery, ear, nose and throat, trauma and orthopaedics, ophthalmology, urology, and gynaecology.
Recent initiatives have included the WOMB (Women’s Outpatients Management Blitz) project that saw around 440 patients across six weeks at the start of this year; two months ago, we tripled the volume of surgery in one theatre on one day; and the collaborative work we’re involved in to reduce waiting times for those with stomach and digestive problems in north east London (NEL) has won a national award.
Our cancer work is showing marked improvement. We have cut our waiting list so significantly that we are the second-best acute provider in the country for reducing the number of people waiting more than 62 days.
We have turned a significant corner when it comes to the provision of diagnostic tests and procedures. The graphs I have attached at the end of this report show how, from a low point last summer – when we discovered several thousand people waiting for routine radiology investigations had been left off our waiting list – we have cut the numbers on the list and the time spent waiting for the tests to be carried out. Against the national performance targets, we now run a fully compliant service.
Strikes by junior doctors
The attached graphs also capture some of the challenges we face in the months ahead. During the two strikes by junior doctors we cancelled 4,731 outpatient appointments and 495 non-urgent surgeries. As a result, the size of our overall waiting list has grown to 65,898, an increase of nearly 5,000. Undaunted, we will continue to cut the time residents wait for treatment and we plan to reduce to zero the number of those waiting more than a year by the end of 2023.
The vast majority of those on our lists need to be seen in Outpatients. The physical space available for conducting such appointments in person is challenging and we are looking at how we transform this service so that people don’t actually have to come into hospital to receive the care they need. When John Hambridge, one of our consultant orthopaedic surgeons, retired last month he reflected that the telephone fracture clinic he helped set up had saved more than 16,000 patient visits a year.
Our drive to cut waiting times will be further imperilled by future strikes. We navigated the first two bouts of industrial action by cancelling appointments and having senior doctors on the ‘shop floor’, providing rapid decision-making in A&E. It’s not a sustainable way of operating.
My concern about the adverse impact of the strikes doesn’t reflect a lack of understanding as to why the junior doctors are taking this action. They are a hugely valuable part of our workforce and I’ve said repeatedly that I support their right to strike. I know they are struggling with the impact of student debt, the cost of living crisis and a real terms drop in pay.
As a country, we are not doing enough to encourage doctors in training to stay in the NHS. We need to see proper negotiations between the government and unions on pay for junior doctors and a suspension of strike action. The longer this dispute goes on, the more it will damage morale and strain relationships across the Trust.
Urgent and emergency care
In the same way that our residents deserve to see waiting lists cut, they are entitled to be dealt with promptly when they present at our A&Es. To help us achieve this, we opened a much larger Same Day Emergency Care (SDEC) department at Queen’s Hospital where people are seen and treated on the same day so they don’t have to be admitted.
Big SDEC, as it’s affectionately known, was only opened a couple of weeks ago at Queen’s - after the last strike by junior doctors - and it is already having a very beneficial impact on our Type 1 performance (treating those patients with threatening injuries or illness). At the time of writing my report, it was looking like April would be our best month for Type 1 performance at Queen’s in nearly two years. We saw daily performance figures of above 50% on at least six days.
Of course, we must do even better and we must reduce the long waits for those who aren’t so ill as to be categorised as Type 1. Under the four-hour A&E waiting time target, at least 95% of all patients should be admitted, transferred or discharged within four hours. Our all types performance in March was 56.5% and we treated 12,180 people in our A&Es.
Five out of every six of these patients come to us via our Urgent Treatment Centres (UTC). They are run by PELC (a GP partnership) and, obviously, any delays in the UTCs adversely affect our performance. We are working very closely with PELC and at KGH our focus is currently on how we improve and speed up the UTC queue.
At a meeting last month of the Joint Health Overview and Scrutiny Committee (JHOSC) Beverley Brewer, a Redbridge councillor, quite rightly described the experience of mental health patients in our A&Es as a “pretty dreadful situation”.
In March we had 29 such patients who waited more than 36 hours to leave our Trust and move to a service better able to care for their needs. A colleague from NELFT, our local mental health and community trust, told the JHOSC meeting that communication with us has improved significantly and they are looking to increase the capacity of their psychiatric liaison team and to continue their work to keep people away from A&E in the first place, by getting them seen in a crisis hub or by their dedicated worker.
We are embarking on a major piece of work to improve what the NHS calls flow - delivering, day in day out, the smooth and continuous movement of patients out of A&E, through the hospitals and back into the community. It’ll involve changes in culture and in the way we think and work together. We will build on the lessons we learnt during the junior doctors’ strikes and we will strive, in the words of one of my senior colleagues, “to do the ordinary well”.
Given the vital importance of flow to improving patient experience, health outcomes and our finances, it makes sense that improving patient flow is one of my two key objectives. Mine, and those of my Executive colleagues, were published at the same time as we set our annual goals for this financial year.
We will have to deliver these goals and objectives while at the same time tightening our belt financially. We hit our deficit target of £14.5m last year. We are likely to have to deliver a deficit that is at least half that size in this financial year. All acute trusts in NEL and across the country face the same financial squeeze in the context of an NHS that, since Covid-19, has seen an increase in funding, a rise in staff numbers and a decrease in productivity.
To deliver our budget we are moving to a position where we no longer pay for any high-cost agency nurses (known as off framework) – around 290 permanent nurses from the UK and abroad will be joining us in the coming months - and we will ensure that our workforce headcount doesn’t increase above 8,500. We are benefitting from the financial improvement plan we are working on with Barts Health as part of our closer collaboration.
As well as improving patient flow, my second main objective for this year is to make BHRUT a better place to work. Our 2022 staff survey results provide plenty of evidence for where we need to improve. One priority area will be the introduction of what we’re calling a Manager’s License which will be designed to ensure that all our leaders have received the training and support they need to do their job well.
We are determined to learn lessons from two recent Employment Tribunals. In one, we were pleased they threw out a claim for unfair dismissal by one of our former senior doctors after we sacked him for sexual harassment. In the other, we were found to have acted in a racist way when we dealt with complaints from two of our colleagues. I have apologised to them both for our failure to respond appropriately when they raised concerns. The tribunal judgement is a wake up call for us. We will continue to strive to become a just and learning organisation and one that doesn’t tolerate racism or any other form of discrimination.
While we tackle these difficult issues, we mustn’t lose sight of what we have achieved. I hope you agree, from reading this report, that we have much to be proud of. The support we offer the nurses and midwives we recruit from other countries has been acknowledged nationally; a simple innovation to reduce infections when changing dressings on c-section wounds has won an award; and we’re delighted to be part of an amazing initiative that is designed to help young adults with a learning disability and/or autism find work. This powerful video captures the transformative nature of the scheme.