Agenda item

This report outlines the key current problems, notably with meeting the four hour waiting time targets.  It cites issues such as increased pressure at Northwick Park Hospital, where Emergency Department attendances have decreased but combined Emergency Department and Urgent Care Centre attendances continue to increase; it also cites issues around long stays in beds and delays in discharge causing a blockage in the emergency pathway.  Attendance at Central Middlesex continues to decline.

Tina Benson presented the report and stated that the North West London Hospitals (NWLH) Trust had held a number of discussions, including a risk summit, with staff and other stakeholders to explore ways of reorganising emergency services across both Central Middlesex Hospital (CMH) and Northwick Park Hospital (NPH), to make best use of staff and other resources.  A project board had been created and set up three workstreams underpinned by a number of projects, which will require the support of all key health and social care partners to deliver:-

·         Increasing bed capacity at NPH

·         Maximising capacity at CMH

·         Moving more orthopaedic work to CMH

Tina Benson explained that for CMH, the changes in particular focused on moving recovery and rehabilitation care to the hospital for patients who had received surgery for hip fractures.  It was also proposed to have an enhanced recovery programme.  CMH would sustain an acute medical intake to treat patients with a medical problem, whether they arrived by ambulance or through GP referral, at any time day or night.  Currently ambulance arrivals were not accepted out of hours, but this was being discussed with the London Ambulance Service.  With regard to NPH, additional bed space on existing wards, including a short term change of 11 private beds on Sainsbury Ward to NHS beds would be undertaken.  It was also intended to expand the ambulatory care unit and surgical assessment unit on Fletcher Ward to include the STARRS assessment lounge to accommodate a further 10 to 15 patients a day and move STARRS to focus on the Emergency Department to prevent unnecessary admissions.  Other measures included patients in need of a surgical assessment not necessarily having to be assessed in the Emergency Department first and being referred directly to the relevant consultant depending on their condition.  Work had also started on a new Emergency Department and state-of-the-art operating theatres at NPH. 

During discussion, clarification was sought in respect of acute medical intake at CMH and whether staff numbers would be increased in order that it could remain open at night and was there the budget to be able to do this.  Moreover, would the hours be extended at CMH in the event of additional staff being recruited in any case and what was the recruitment policy for the hospitals.  Comments were sought as to whether the patient footfall remained low at CMH and was this an attributable reason for the difficulty in recruiting staff there.  Members also noted the concerns of residents to the ongoing evening closure of the Accident and Emergency (A and E) department at CMH and it was enquired what was being done to improve communication with residents in the area to keep them informed of services available at the hospital. It was also asked if A and E targets at CMH were being met and were residents in the area visiting A and E less, and if so, where were those who were in a serious condition being treated.  Furthermore, was there an increase in the number of patients being taken to CMH by ambulance and was there an issue between patients arriving by ambulance and waiting times at hospitals in the borough.

A member queried whether dealing with patient numbers at NPH remained a serious challenge.  Further explanation was sought in respect of the risk summit, including what they were, why they had happened and why had they not been mentioned at the previous meeting of this committee.  A member asked if the council had been informed about the outcome of the risk summit.  Details were also asked about the inspection that had been carried out in November 2012 and what had instigated it.  Another member, in noting the need to improve out of hospital care, sought an update on progress in this area.  The number of cancellations of planned surgeries in the last three months was also asked.

With the agreement of the Chair, Councillor Cheese addressed the committee.  Councillor Cheese asserted that the London Ambulance Service was diverting patients to CMH because NPH was so busy, and because less services were available at CMH, this was putting patients in the south of the borough at risk and he asked what was being done to address this.

In reply to the issues raised, Tina Benson advised that discussions were underway with regard to acute services at CMH, with one of the suggestions being that patients will be admitted to the hospital at night irrespective of whether the A and E unit was open or not.  She confirmed that an additional consultant had been recruited at CMH, however there remained nine vacancies.  Although patient numbers remained a challenge for NPH, performance had improved and the waiting times in May 2013 had been met.  However, patient demand was always greater in winter and every effort was being made to improve waiting times next winter in comparison with the last.  Tina Benson advised that the risk summit looked at all the risks the health economy posed for emergency care and there had been a number of workshops focused on performance, risks to patients and the patients’ experience.  It was noted that the borough based Urgent Care Board now led the response to the risk summit and workshops.  With regard to the inspection of A and E in November 2013, this was as a result of a complaint received about a patient’s experience and featured inspections carried out both during the day and night.  The inspection had resulted in a favourable report and Tina Benson agreed to provide members with information on this.  An audit of 40 patients waiting at A and E had also been undertaken and this had shown that all of them had received the care and treatment required and Tina Benson added that this information could be made available to members if they so wished.  She also agreed to undertake to provide information on the number of cancelled planned surgeries over the last three months. 

Tina Benson advised that there was not sufficient staff numbers to extend A and E hours at CMH, however if extra staff were recruited, this could be looked at again.  The committee heard that staff were recruited as employees of the Trust as opposed to a specific hospital.  A budget was currently available to increase staff numbers at CMH, however it needed to be noted that patient numbers particularly in respect of A and E continued to fall.  The committee was informed that CMH A and E was meeting its waiting target, although it did see a considerably lower volume of patients than NPH and St Mary’s Hospital, which found it easier to recruit staff as it was a major trauma centre.  Tina Benson confirmed that presently there were 18 private bed spaces at NPH, although 11 of these were to be reallocated to the Trust. Tina Benson advised that data sharing with partner agencies was taking place to look at specific needs of patients, particularly in relation to out of hospital care.

Jo Ohlson added that prevention of unnecessary visits to hospitals was a key driver in respect of improving out of hospital care and STARRS played an important role in this, with hospital patients referred to them where appropriate.  The Willesden Centre for Health and Care also provided therapy weekends and there was a robust protocol in place as to when patients could be discharged from hospital.  With regard to A and Es, Jo Ohlson advised that the excellent clinical service required of them was only feasible at NPH, as CMH lacked the necessary support services. The Urgent Care Centre (UCC) also operated on a 24/7 basis at CMH and around 85% of cases were admitted to it.  It was noted that the UCC could also refer patients to the appropriate medical practitioners.

David Cheesman  (Director of Strategy, NWLHT) added that the UCC had been very successful since opening at the CMH and had exceeded expectations.  He also advised that the composition of health services was being reviewed at macro level through the Shaping a Healthier Future Programme.  He acknowledged that explaining the health services available was complex, however it was intended to increase utilisation of each hospital. 

Pauline Cranmer (Performance Improvement Manager, London Ambulance Service: West London) advised that the London Ambulance Service was working with UCCs  to identify the most appropriate locations to send patients to.  During April 2013, around 2,800 patients had been sent by ambulance to NPH, and 670 to CMH.  Pauline Cranmer advised that waiting times in A and Es was a London-wide issue, due to increases in patient demand and in acute cases.  She added that for critically ill patients, these would be categorised as blue light calls and the hospital concerned would be duly informed so that staff were waiting at the entrance of the hospital to attend to the patient as soon as they arrived. 

Phil Porter (Interim Director of Adult Social Services) confirmed that while he had not attended the risk summit, he was aware of the outcome and the council was represented on the Urgent Care Board that was overseeing the three work streams.

The committee noted that the council was informed of the outcome of the risk assessment on 6 March 2013.

The Chair felt that the waiting times for A and E patients were not acceptable at present, whilst she also commented that there needed to be more clarity as to where residents would be treated depending on their condition.  She requested an update on A and E, the London Ambulance Service, treatment provided to patients at home and clarification with regard to services at CMH for the next meeting on 24 July 2013.