Agenda item

This report provides information to the Community and Wellbeing Scrutiny Committee on the A&E Performance at Northwick Park Hospital and St Mary’s Hospital.

The Chair invited Simon Crawford (Director of Strategy and Deputy Chief Executive, London North West Healthcare NHS Trust (LNWHT) to introduce the item for discussion. Simon Crawford began by highlighting that the past year had been unusual because of responding to COVID-19 and the challenges in the NHS and at Northwick Park in particular. He explained that 3 March 2020 was when Northwick Park had their first patient admitted with COVID-19. The hospital was under great challenge and one of the hardest hit in the early wave of the pandemic, and there was a need to respond significantly during that early wave in March and April 2020 to ensure the hospitals were not overwhelmed with presentations. This meant treating patients coming through A & E differently depending on their presentations of symptoms, learning new processes and procedures around PPE, infection control, treatment modalities and then standing down elective procedures and processes and focussing the whole response of the hospital to COVID-19. In particular, patients coming through A & E and those most critically unwell needing access to critical care beds. As part of that response beds were increased from 22 to a maximum of 50 critical care beds in Northwick Park Hospital and significantly increased High Dependency Unit (HDU) capacity from 18 beds pre-Covid to 33. This presented a logistical issue such as getting more monitors, equipment and retraining staff to support those beds. Protected pathways were also introduced such as green pathways for those without COVID-19 and red for those with COVID-19. Staff protected patients as best as possible from getting infected within the hospital. In the first wave of COVID-19 the majority of elective care was stood down, but during the second wave and using the learning from the first wave Central Middlesex Hospital and the independent sector maintained 20-30% of elective activity. Cancer patients were also seen at the Royal Marsden Clinic, London Clinic and Cromwell Hospital. Maternity services continued to be offered and there had been 4,000 births during the period.

Jon Baker (Divisional Clinical Director for Emergency and Ambulatory Care, Northwick Park Hospital) highlighted that Northwick Park Hospital was now number one in London for A & E performance and third in the country, which he noted was a huge difference to where it was when he started working there, particularly given Northwick Park was one of the busiest hospitals in London most days. He advised the Committee that Northwick Park now delivered prompt emergency care and received most ambulances, dealing with those the quickest compared to the rest of London. He felt that there was partner working end to end with the pathway starting at the front door and nurse consultants who had helped overhaul the pathways of moving ambulance patients through the system. This included what was nationally known as same day emergency care, managing patients in a more comfortable speedy environment where patients who would have in the past been admitted overnight were now seen in a large emergency floor and could leave the same day. The majority of patients presenting to A & E were medical emergencies such as heart attacks and strokes, with 6 medical consultants responding in the centre of the hospital to those. Covid patients could be seen virtually which helped with the flow to deal with the most sick patients.

Professor Frances Bowen (Interim Divisional Director of Medicine and Integrated Care, Imperial College Healthcare NHS Trust) advised that St Mary’s Hospital was not able to report performance in league tables at the moment as they had been piloting new standards, but similar to Northwick Park during the first and second waves of COVID-19 had ensured rapid assessment of patients in the emergency department with a good change of pathways with Vocare and Urgent Treatment Centres to ensure potentially high risk patients were in one area. There had been a large expansion of the same day emergency care pathways and redeployment, such as surgeons who were not doing elective activity during the first wave taking on minor injury patients. In the second wave of COVID-19 therapists and neurologists were used to support the response. They had supported other hospitals who were a few weeks ahead in terms of responding to the COVID-19 waves through ambulances being diverted to who was able to take the next ambulance and enable early offloading of patients. She advised that collaborative working worked well together and there had been some good learning and now a better understanding of responding to the virus, meaning the following winter the sector would be well prepared.

The Chair thanked the health colleagues for their introductions and invited the Committee to raise comments and questions, with the following issues raised:

The Committee noted that all but time critical planned care had been cancelled and queried what was meant by time critical and how many appointments had been cancelled as a result. Simon Crawford advised that all elective procedures had been cancelled at the Northwick Park site but some activity was diverted to Central Middlesex Hospital. Northwick Park had still conducted emergency surgery for people coming through A & E and arrangements were put in place with the independent sector such as BMI The Clementine Churchill Hospital to maintain the most urgent cancer treatments in both waves of the virus. There was now more elective activity at Central Middlesex Hospital and Northwick Park had began bringing elective activity back. Frances Bowen advised that at St Mary’s Hospital they only operated on the most extreme traumas and outpatients were maintained virtually during the first and second waves of the pandemic.

Simon Crawford advised that the plan for LNWHT regarding elective activity was to return to September 2020 elective activity by the end of June 2021 as part of the Integrated Care System (ICS) planning framework across NWL and to return to pre-Covid activity, dependent on any further waves, by late autumn. This was also the case for St Mary’s Hospital. In relation to cancer care and treatments, Simon Crawford advised that they had focused in terms of the highest priority patients and tried to maintain access to services for cancer patients. This had not necessarily been done within the Trust as the Trust had arrangements in place with BMI The Clementine Churchill Hospital, Harrow on the Hill and The Royal Marsden to source high priority procedures, so the Trust had managed to maintain delivery of cancer services for Priority 2, 14-day, cancer patients. Frances Bowen advised that St Mary’s Hospital had managed a huge amount of priority 2 work and urgent cardiac and non-cancer work. All cancer specialities had been managed equally with no particular speciality disadvantaged. Lesley Watts (Chief Executive for the North West London Integrated Care System) added that across London there was a set of emerging principles for elected programmes which would change how things were done in the future. She advised that as that work was iterated across London and North West London it would be brought back to the Committee, with the aim being to ensure equality of access across the patch particularly in Brent.

The Committee noted the improvement in performance from the first wave of the pandemic to the second wave and asked what impact the second wave had on people needing operations. Simon Crawford acknowledged that the second wave had not been easier than the first wave but they did have the benefit of the learning from the first wave, meaning the sector was better organised for treatment, modalities, PPE, systems and collaborative working. Frances Bowen added that the second wave at Imperial College London and St Mary’s Hospitals was very difficult and beds increased to 150, with extremely tired staff. The hospital had continued with urgent cancer endoscopy and urgent cancer operations during the second wave. The hospital had been balancing the intensive care needs of patients with patients that were in acute respiratory units as well as doing urgent care which had been a lot to do. Some treatments trialled in the second wave had been really beneficial so outcomes for patients during the second wave were outstanding.

In response to Committee members asking if there were any teething problems from the pilot of the 111 time slots, Frances Bowen advised that the pilot had only been booking around 4-5 slots per day and it had not made much difference to the workflow through the emergency department. The pilot had not been as successful as the initial launch suggested it might be and they had not been informed of any issues around waiting times.

Discussion was held regarding the potential for digital exclusion as a result of virtual clinics. Jon Baker advised that the majority of emergency work came through the emergency department rather than virtually, then if possible a patient could be followed up virtually. If a patient had come into hospital and was assessed as well enough to go home they could be sent home with an oximeter to measure oxygen levels and could call with any issues. If a patient was not able to use the device they would either be kept in hospital or managed in a different way to ensure there was no discrimination.

In relation to staffing, the Committee noted the recent Panorama documentary focusing on comparisons in the Coventry Hospital now and a year ago and that a number of staff had left, and asked how the hospitals in North West London were getting on in that respect. The Committee heard that Northwick Park had done a lot of work with staff since the crisis and focused a huge amount of work on wellbeing in what had been a highly stressful period. Jon Baker reflected that some staff were more used to high pressure situations such as staff within the emergency team and were therefore more ready but they had been conscious many staff had moved across the trust into different areas and therefore those staff were being provided support. Frances Bowen added that at St Mary’s Hospitals a lot of staff had been redeployed and there was a focus on staff wellbeing and allowing staff some rest.

The Committee queried whether the hospitals had seen an increase in admissions to A&E due to domestic abuse or mental health issues. Jon Baker advised that sadly they did see people coming through the department due to mental health issues or domestic abuse and felt that was the case for most shifts he worked. The past few weeks had seen a heavy spike in presentations of mental health issues and there were teams to support this in the community and the Trust and a domestic abuse advisor within the department. In addition there was a youth support service at St Giles’ Trust commissioned by Brent Council and psychiatric liaison nurses worked parallel with clinicians at the front door. Robyn Doran (Chief Operating Officer, Central and North West London NHS Trust) added that there had also been an increase in presentations at Central North West London NHS Foundation Trust that week in particular with a lot more children and young people presenting and more adults who were not known to the service. It was acknowledged that COVID-19 had impacted on the number of people who had never been seen in services before and the rise in children and young people presenting was suggested to be linked to young people going back to school.

The Committee asked for assurance that health partners were embedding new ways of working to ensure performance targets continued to improve going forward. Simon Crawford agreed it was important those ways of working were embedded, and across the ICS they had learnt the importance of working together in a joined up way. He assured the Committee LNWHT were embedding new practices and ensuring those were sustained and highlighted the acute medical model at Northwick Park with changes to the front door and the way patients were assessed. In response to COVID-19 a lot of attention had been given to discharge planning and consultant timings and supporting in a robust way which was becoming embedded into the normal way of doing things. Frances Bowen added that they had learnt how to flip pathways so that emergency pathways could become high, medium or low risk, could move structures and staff around and could confirm they had areas they could safely bring patients in for elective operations. She felt that COVID-19 had brought on a speed of transformation that many had never seen previously, with learnings from the first wave transferred to the second wave and consultants working together deployed to the front door and embedded in STP, pathways, discharges and communities. She advised that the process of allowing staff to recover and ensure these new processes were embedded had been hugely beneficial to people coming through the front door.

The Chair drew the item to a close and invited the Committee to make recommendations, with the following RESOLVED:

i)              To note the performance report.