HSJ Live 16.01.2015: Single board to share risk across Cambridgeshire health economy

Draft guidelines from NICE, published today, outline new nurse staffing requirements for consultant led major A&E departments across England, aimed at ensuring safe care.

It is the first time NICE has recommended minimum ratios for nursing establishment and follows an earlier refusal to set minimum levels for hospital wards.

1.26pm NHS Providers welcomes ‘sensible’ pilots of new approach to ambulance performance targets Sivakumar Anandaciva, NHS Providers’ head of analysis said: “These are sensible proposals which could have a real, positive impact on improving the clinical  outcomes of patients with the most critical health needs. 

It makes sense to review targets against the latest clinical knowledge and experience and consider evidence from trials and the impact of new technology.  Whilst responding to the highest ever demand for services in history, NHS Providers’ ambulance trust members have also been at the forefront of researching how to improve the safety and clinical effectiveness of treatments for patients to ensure they receive the most timely and clinically appropriate response for their condition.

“Ambulance services will continue to deliver world-class response times for patients but as we have seen with the reconfiguration of stroke services in London, improving health outcomes for patients relies on receiving the most effective clinical response not simply the quickest.

“We welcome the government’s decision to pilot extensions to call handling time for lower risk ambulance calls, and establish the evidence needed to make the right and safe decisions on how to improve the use of ambulance response time standards. 

“This approach, based on clinical expertise and engaging both patients and the public, is an excellent model which could be used to look at a wider range of performance targets across the NHS that might benefit from being reviewed to see of they are still achieving the improvements in patient care they were created for.”

1.15pm Commenting on the story, HSJ Alastair McLellan tweeted this morning:

Long running campaign against @cmoMD as leader of Hinchingbrooke inspection team goes public http://t.co/qrwpvrMPF8 Ridiculous accusation

— Alastair McLellan (@HSJEditor) January 16, 2015

1.15pm The Sun today reports that two of the Care Quality Commission team that wrote what is described as a ‘daming’ inspection report into the Circle-run Hinchingbrooke Hospital are ‘biased’ and ‘anti-privatisation’.

Leader of the inspection team Dr Jonathan Fielden, medical director of University College London Hospitals Foundation Trust, is particuarly singled out for criticism.

12.22pm The news on NHS England’s decision to delay sofosbuvir’s introduction comes after an exclusive story broken by HSJ last October.

In a move described as setting a “dangerous precedent”, an internal NHS England briefing note - seen by HSJ - described the cost of offering sofosbuvir to patients as suggested by the National Institute for Health and Care Excellence as “prohibitive”.

The note puts the price tag of prescribing the drug in line with NICE recommendations of £1bn in 2015.

11.55am On its front page, The Guardian reports that NHS England plans to delay the introduction of a very expensive drug used for treating hepatitis C virus.

The move is unprecedented for the NHS because the drug sofosbuvir has been approved by the National Institute for Health and Care Excellence.

NICE has determined that sofosbuvir is cost-effective, because it provides a cure for people infected with hepatitis C who would otherwise run up high NHS bills.

Also in The Guardian, patients should be moved out of busy accident and emergency units when they become so overcrowded or short-staffed of nurses that they poses a danger, the National Institute for Health and Care Excellence has recommended.

11.50am The Nursing and Midwifery Council has today launched a consultation to remove time limits for the completion of education programmes.

Currently, student nurses and midwives are required to finish full-time programmes within five years and part-time programmes within seven years in order to be eligible for registration.

The NMC proposes to remove these maximum time limits from NMC standards, while ensuring full responsibility for the management of education programmes lies with approved education institutions. Post-registration programmes, which are currently given time limits either by the NMC or by the specific education institution, will also be affected by the proposed changes.

The removal of time limits enables greater flexibility for students ensuring that no individual is disadvantaged if unforeseen events interrupt their studies. The education institutions are best placed to oversee students’ involvement in their programmes.

Chief executive and registrar of the NMC, Jackie Smith, said: “The NMC protects the public by ensuring all those who enter or remain on the register meet the standards to do so. This is an important consultation and we are keen to hear views. Removing time limits from our education standards would ensure that education institutions provide flexibility for students without compromising public protection.”

The consultation on the proposed changes will take place between 15 January 2015 and 12 March 2015.

11.48am Research published today by the Journal of the Royal Society of Medicine concludes that patients admitted to hospital from care homes are commonly dehydrated on admission and consequently appear to experience significantly greater risks of in-hospital mortality.
 
Old and infirm people are at increased risk of dehydration, especially if they require assistance with drinking and, left to themselves, may not drink enough to avoid dehydration.

Dehydration leads to high sodium levels, which can have severe consequences and which are an independent predictor of in-hospital mortality.

Researchers from what was formerly Barnet and Chase Farm Hospitals Trust, the University of Oxford and the London School of Hygiene & Tropical Medicine reviewed over 20,000 patients aged 65 years and over admitted to a London hospital trust for the first time between January 2011 and December 2013.

While 1 per cent of patients admitted from their own home were found to have high sodium levels, the figure for patients admitted from care homes was 12%. After adjustment for a number of possible explanatory factors, including age and dementia, the risk of high sodium levels was still over five times higher for those admitted from care homes.

Lead researcher Dr Anthony Wolff, of the Royal Free London NHS Foundation Trust, which acquired Barnet and Chase Farm Hospitals in July 2014, said: “Our study shows that too many patients admitted to hospital from a substantial number of care homes are dehydrated, leading to unnecessary loss of life. High sodium levels in care home residents should raise questions about adequate support for drinking.”
 
Professor Martin McKee of the London School of Hygiene & Tropical Medicine and co-author of the research paper, added: “This raises serious concerns about the quality of care provided in some care homes. When a care home has more than a few residents admitted to hospital with high sodium levels this may well be indicative of a systematic problem at the care home and the issue should be raised formally”.
 
Co-author Professor David Stuckler, from the University of Oxford, said: “Clearly this level of dehydration is a problem. Further research is needed to understand why it is occurring. Are care home residents choosing to drink less than they should? Or, as has been speculated, are care home staff not offering enough water to reduce incontinence and the amount of assistance their residents require?”

11.45am The Telegraph reports that A&E departments will be forced to tell the public if they have unsafe nursing levels following guidance stating that there should be a maximum of four patients per nurse.

NICE suggests that many units are desperately short-staffed and fail to provide enough staff to meet the needs of acutely ill patients.

The NHS has reportedly delayed the introduction of a £400 a day drug that could cure hepatitis C, The Telegraph reports.

NICE has approved sofosbuvir on the grounds that it is a cost-effective way to save the lives of people who would otherwise run up large medical bills.

But NHS England is understood to have delayed the introduction of the drug on the grounds that it will cost £1bn for every 20,000 treated, The Guardian reported.

11.05am The Medical Protection Society welcomes the General Medical Council’s commitment to review the way it treats vulnerable doctors under fitness to practise investigations.
Dr Richard Stacey, Senior Medicolegal Adviser at MPS said: “MPS is pleased that recommendations have been made to address the way in which fitness to practice investigations can affect vulnerable doctors. We are well aware of the serious impact a GMC investigation can have on a doctor’s mental and/or physical health.

“Our recent survey of 180 doctors investigated by the GMC in the last five years found that 93 per cent of respondents involved in GMC investigations felt that it had impacted on their stress/anxiety. 72 per cent believed that the investigation had a detrimental impact on their mental and/or physical health.

“While we are still examining the detail of the recommendations, we hope that if implemented appropriately, they will begin to make a difference to the lives of doctors.”

Commenting on recommendation one Dr Stacey said: “In some cases, a letter informing a doctor that they are the subject of a GMC investigation can ignite feelings of fear and anxiety as the wording can appear formal and overly legalistic.

“MPS acknowledges that the GMC has recently taken steps to alter the wording of correspondence with doctors being investigated; however it is clear that more needs to be done. The wording must be improved to ensure that content can be easily understood by people with non-legal backgrounds and the tone should be softened and demonstrate greater compassion.”

Commenting on recommendation nine, Dr Stacey said: “We warmly welcome the concept of a national support network for doctors. We understand how important support of this kind is which is why we offer a confidential counselling service as a benefit of MPS membership. However the network would need to have appropriate confidentiality safeguards, and be adequately funded. It is important that doctors suffering with mental or physical problems relating to stress and/or anxiety get help early but also know that any information they share will be completely confidential.”

“The GMC has committed to a meeting early next year to discuss what a national service might look like; we are keen to be a part of these discussions.”
Our survey found that almost half of respondents (47%) did not believe they received enough support in looking after their health throughout the investigation. 70% of respondents said that the General Medical Council should offer more support to doctors facing an investigation.
The survey also revealed:

• Respondents’ involvement in GMC investigations impacted on their personal life (76%), health and wellbeing (74%), confidence (69%) and professional reputation (52%)
• 28% considered leaving the medical profession as a result of their experience
• 8% changed their role, and 2% left the profession
• 77% of respondents to the survey sought help or support for their health issues from family or friends, and 62% sought assistance from colleagues.

10.45am NHS England have just issued the following statement:

The NHS Five Year Forward View set out a radical vision of dissolving the traditional divide between primary care, community services, and hospitals – largely unaltered since the birth of the NHS, and increasingly a barrier to the  personalised and coordinated health services patients need.

In December, NHS England and its partners  initiated a programme to partner with a selection of vanguard areas wishing to implement the new care models discussed in the Five year forward view, and many local health economy leaders are now developing their EOIs for early February as part of the vanguard selection process

In response to all the strong interest being shown across the country in being part of the models of care programme, NHS England and the Kings Fund will now be hosting an all day event on Friday 23^rd January – open to all with an interest in the models of care programme - to discuss international experience in implementing new care models and to explore some of the most promising programmes here in the UK. Speakers at the event will include Simon Stevens and Don Berwick – who has now been engaged as an international advisor to this programme. In addition the newly appointed director of the models of care programme (Sam Jones) and the lead for MCP models (Sir Sam Everington) will also be participating in this event

We have a limited number of places available at this event. If you are a senior leader in the health and care system and have a strong interest in the new models of care vanguard programme, please email The King’s Fund event team (events@kingsfund.org.uk) by 5pm on Monday 19^th January.

10.32am In a statement made to parliament this morning, health secretary Jeremy Hunt said: “Today I am announcing that NHS England is to pilot a possible change to the way ambulance services respond to 999 calls, based on clinical advice that this will improve the chances of survival for patients, especially those with the most serious conditions.

“In light of the unprecedented increase in demand for ambulance services in the last two months, I asked NHS England to consider whether there were any changes which could be brought forward quickly in order to help ambulance services maintain, and perhaps even improve, clinical outcomes for patients.

“I have now received and considered NHS England’s advice. A copy of the letter from Professor Keith Willett, the national director for acute care at NHS England, with his recommendations, is attached and has been placed in the House Library.

“I agree with his advice that there is significant evidence to suggest that giving call handlers extra assessment time to make the right decision for the patient could improve clinical outcomes and improve their chances of survival. At present, ambulance services are allowed only 60 seconds before the clock starts to decide what the right course of action is for that individual patient.

“This sometimes leads to ambulances being dispatched unnecessarily, so that fewer ambulances are available for patients who really do need emergency assistance.

“In the interests of patient safety, I therefore agree that giving call handlers very limited extra assessment time would ensure that ambulances are better deployed to where they are most needed and would allow a faster response time for those patients who really need it.

“I have agreed to two local pilots where call handlers will be allowed up to a maximum of an additional 120 seconds for assessment, before the clock starts, for all 999 calls. This will not include those calls which are immediately life threatening (categorised as Red 1 calls). The pilot will therefore allow for a maximum of 180 seconds to assess a call, in order to reach a more detailed diagnosis and send the most appropriate response.

“In these pilot sites, a small number of potentially life threatening conditions, such as overdoses and certain types of gunshot wounds, will also be upgraded from the Red 2 category into the Red 1 category so they receive a faster response than is currently the case.

“The two pilot sites will be South West Ambulance Service NHS Trust and the London Ambulance Service NHS Trust – one running the NHS Pathways triage system and one running the Advanced Medical Priority Dispatch System. The pilots will start in February and will jointly cover a patient population of around 13 million people.

“During the pilot, ambulance targets for all other areas will not be changed. We will continue to publish national data as normal, and the pilot data will be published alongside this in the interests of transparency. Given the pilots will only be affecting two ambulance services for a very limited period of time at the end of the reporting year, we do not anticipate that this will have a significant impact on the overall national data.

“The pilot will be subject to rigorous and independent external evaluation which will be published. I will not support any extension of this pilot more widely unless the following 3 tests are met:

• There is clear clinical consensus that the proposed change will be beneficial to patient outcomes as a whole, and will act to reduce overall clinical risk in the system.
• There is evidence from the analysis of existing data and piloting that the proposed change will have the intended benefits, and is safe for patients.
• There is an associated increase in operational efficiency. The aim is to reduce the average number of vehicles allocated to each 999 call and the ambulance utilisation rate.

“After the evaluation has been published, I will consider the outcomes of the three tests and the findings of this external evaluation before making any decisions to implement these changes throughout England.”

10.30am Pressure eased slightly on hospitals last week as accident and emergency departments saw a drop in admissions and attendances compared to the previous week, according to the latest figures from NHS England.

This lessening of demand allowed A&Es to improve their performance slightly against the target to treat, admit or discharge patients with 84.3 per cent of patients at major A&Es seen within four hours.

However, this was still the third worst performance on record against the four hour target.

Only nine trusts managed to meet the 95 per cent four hour target.

There were 75,546 emergency admissions via major A&Es last week compared to 80,049 the previous week.

Attendances to major A&Es were at their lowest level since December 2013. There were 249,648 attendances, a drop from the previous week when 266,281 attended.

10.21am The Times reports that thousands of elderly care home residents are admitted to hospital suffering from dehydration, according to research revealing widespread neglect.

One in eight patients admitted from residential care had high sodium levels from lack of fluids, the study by Oxford University, the London School of Hygiene & Tropical Medicine and the Royal Free London Foundation Trust revealed.

The figure was five times higher than for those who were hospitalised from their own homes.

Also in The Times, a drug to treat Hepatitis C that costs up to £70,000 per course of treatment is set to be approved by the National Institute for Health and Care Excellence.

The recommendation of sofosbuvir for the majority of patients with chronic hepatitis C comes after severally similarly priced drugs were removed from the Cancer Drugs Fund.

The Times reports that Labour “rowed back” from banning alcohol brands from sports sponsorship and was forced to discard other policies after internal disagreements.

The paper reports that the shadow health secretary Andy Burnham, who unveiled the party’s public health manifesto yesterday, was pushing to introduce a levy on pubs, a minimum price on alcohol and restrictions on the visibility of alcohol in supermarkets.

However the policies were met by resistance from senior Labour MPs who believe they would appear draconian and be unpopular among businesses, it reports.

A Times leader says that Mr Burnham’s plans to introduce maximum levels of sugar and food marketed to children are part of the solution to childhood obesity.

“The next government must be ready to try anything that works,” it argues.

However it concludes by saying “In the end… parents must understand that only they can make sure their children eat better food, and less of it.”

7.00am Good morning and welcome to HSJ Live.

We start with the news that providers and commissioners across Cambridgeshire and Peterborough have created a joint board for strategic planning which they hope will ultimately share financial risk across the health economy.