This HSJ Local Briefing looks at how to reverse a decline in performance at Bristol’s A&E departments.
C3AJWM Clifton Suspension Bridge. Bristol. England. UK.
ISSUE: Performance against the four-hour accident and emergency standard in Bristol began deteriorating last year and has been poor at all three acute trusts in the Bristol, North Somerset and South Gloucestershire primary care trust cluster. Although University Hospitals Bristol Foundation Trust and Weston Area Health Trust have started meeting the target in recent weeks, North Bristol Trust is still struggling and commissioners remain extremely concerned. This is also causing problems for Great Western Ambulance Service Trust.
CONTEXT: Admitting or treating and discharging 95 per cent of patients within four hours is a key national performance measure and part of Monitor’s compliance framework. As well as poor patient outcomes, continuing poor performance could also have implications for North Bristol’s foundation trust application which went to the Department of Health earlier this year.
OUTCOME: A sustained focus on patient flow by the trusts and commissioners is showing results while there is hope new initiatives coming down the line will help tackle high lengths of stay at all trusts.
The national context
Treating the vast majority of patients who arrive at accident and emergency departments within four hours has been a key national performance measure since it was introduced by the Labour government in 2004. Then the standard was for 98 per cent of patients to be treated and discharged or admitted within the time frame. By the time of the 2010 general election the majority of trusts were meeting this target most of the time. However, the coalition government reduced the target to 95 per cent when it took office. The move had the backing of much of the emergency medicine community, who argued that 98 per cent was too high and distorted priorities. Performance against the revised standard has generally been good: during the first quarter of 2012-13 it was met nationally in nine out of 13 weeks. Where the target was missed it was by a maximum of 0.6 per cent.
Part of the foundation trust regulator Monitor’s compliance framework, failure to meet the standard during a quarter gives a governance risk rating score of 1. Failure to meet it in three quarters of any 12-month period can result in a red rating for governance and potential escalation. For an aspirant foundation trust poor performance can have implications for authorisation.
Up until last year all three trusts serving the Bristol, North Somerset and South Gloucestershire primary care trust cluster area had been meeting the four hour standard fairly consistently. In 2010-11 University Hospitals Bristol Foundation Trust reported overall performance of 96.2 per cent; North Bristol Trust 97.1 per cent and the smaller district general hospital Weston Area Health Trust 95.8 per cent, according to commissioner performance data. However, North Bristol Trust’s performance began to deteriorate halfway through 2011-12 and the trust reported overall performance of 94 per cent for the year. At the end of May year to date performance stood at 88.8 per cent (Bristol CCG performance report). Department of Health published figures show performance continued to be under 90 per cent throughout June, in one week reaching a low of 80.6 per cent.
Down the M5 in North Somerset, Weston Area Health Trust had been struggling to meet the target since November 2010, finishing 2011-12 with performance of 93.5 per cent. Then in December University Hospitals Bristol began failing the target as well. It went on to fail the target during the last quarter of 2011-12 and the first quarter of 2012-13, despite achieving it in June. In May, Monitor downgraded the trust’s governance risk rating from green to amber-green for quarter four of 2011-12 in light of poor performance against the four-hour standard. The trust has continued to declare an amber-green rating in the first quarter of 2012-13. The Department of Heath emergency care intensive support team was called in and has visited all three acute trusts as well as carrying out a whole system analysis.
Overcrowding in the accident and emergency departments at UH Bristol’s Bristol Royal Infirmary and North Bristol Trust’s Frenchay Hospital has led to long delays in ambulance handover times. Great Western Ambulance Service estimates it has lost 6,300 hours of ambulance time due to its crews being forced to queue outside emergency departments between January and June, with most of the problem in the Bristol, North Somerset and South Gloucestershire cluster area. For example, in January this year 58.5 per cent of ambulance handovers at Frenchay Hospital took longer than 15 minutes, as did 38.3 per cent of those at the Bristol Royal Infirmary and 25.3 per cent of those at Weston. This compares with less than 10 per cent at both Royal United Hospitals Bath and Salisbury Foundation Trust.
The issue also appears to have had a knock-on effect on the ambulance trust’s performance against requirement to reach 75 per cent of the most serious life-threatening calls within eight minutes, a key performance target for ambulance trusts. Although the trust was meeting the target overall, in South Gloucestershire - the area served mainly by North Bristol Trust - performance was just 69 per cent. Although there is always a variation between rural and urban areas, performance in Bristol was 82.6 per cent, a recent report to the South Gloucestershire Clinical Commissioning Group noted performance was worsening.
What’s going on?
Across the cluster area demand remained fairly flat during 2011-12 compared with the previous year. There was an increase in attendances of about 1 per cent, in line with the national picture. Overall emergency admissions fell by about 3 per cent, slightly above the national average. North Bristol Trust saw an increase in attendances of about 1.4 per cent year on year. Emergency admissions through accident and emergency were up by a staggering 9.9 per cent. However, overall non-elective admissions saw just a 1.3 per cent rise. The trust has also experienced changes to its activity patterns since October 2011, with more patients arriving at 5pm-7pm. A report to a recent meeting of the South Gloucestershire Council overview and scrutiny committee said “traditionally” most emergencies were received before midday but this pattern had changed with just 15 per cent being seen before 12 noon. The report said the later arrivals had led to an increase in average length of stay of half a day.
HSJ understands the change was influenced by the introduction of a “common approach” to urgent care across South Gloucestershire. Under the approach the Orchard Medical Centre stopped treating non-urgent patients and referred them back to their own GP. The aim of this was to create more urgent care capacity in the community but there is anecdotal evidence that individuals turned away from here have been attending Frenchay’s A&E instead. In addition, GPs were required to go through the Common Approach Portal, run by out-of-hours provider Frendoc, rather than refer directly to the trust with the aim of finding a more appropriate community or social care solution. Again there is some anecdotal evidence that some of these patients were arriving at the front door while the change also had an impact on throughput. However, the trust believes the impact to have been “minimal”. Nevertheless this has now been abandoned and GPs are referring patients directly again.
One source locally described the common approach as the “straw that broke the camel’s back” in an already overstretched system. However, Jo Underwood, associate director of urgent care at the Bristol, North Somerset and South Gloucestershire primary care trust cluster, said it was too difficult to pinpoint one factor that led to the deterioration. She described it as disappointing that some blamed the common approach, a system that was “about the community taking responsibility for its patients”.
Ms Underwood, who has been leading on the work to recover performance, said analysis had found “no step changes” to account for the deterioration in performance. She said the only thing that was almost statistically significant was the reduction in proportion of patients conveyed to hospital by Great Western Ambulance Service. Latest figures show the trust is now treating or advising 48.4 per cent of patients without the need for transport to hospital. She said there was no evidence that University Hospitals Bristol’s problems had been the result of a “knock-on effect” from North Bristol Trust.
Length of stay
The whole system analysis carried out by the DH’s emergency care intensive support team found that length of stay was considerably higher than the best performing organisations in all three trusts. Locally, sources attribute some of the blame to a fragmented community health and social care system. Across the PCT cluster area community services are provided by North Somerset Community Partnership and Bristol Community Health while in South Gloucestershire they are hosted by North Bristol Trust pending a full tender which is now expected to take place next year. HSJ understands community services are run as a separate division of North Bristol and are not expected to be there long term, largely because the opportunities for efficiencies are limited without providing services in Bristol as well.
The two city trusts are almost equally as likely to have patients from any of the three community service areas, something that is likely to increase as the city’s acute services reconfiguration plan reduces duplication of services between trusts. This can make it difficult for staff to know who to contact to arrange discharge. Added to this, Bristol City Council uses a number of voluntary and private sector care organisations to deliver social care. It is also clear there is work to do internally on discharge planning and making sure the services are available both internally and externally to allow discharge on weekends.
University Hospitals Bristol FT chief operating officer James Rimmer said the reasons for the trust’s dip in performance were “complex”.
“The trust continues to look at how beds are used within our hospitals to ensure that patients can be discharged efficiently as soon as they are well enough to leave hospital,” he said.
“We are also working closely with health and social care partners across the city to direct patients to the most appropriate local facilities and ensure that hospital services are used appropriately.”
The problems have been also been compounded by reduction in bed capacity at both North Bristol and University Hospitals Bristol. Meanwhile, at UH Bristol staffing has been an issue. The trust has a “military-placed” A&E consultant among its nine strong consultant team and is recruiting for one more. The trust is also recruiting four emergency nurse practitioners. Nursing vacancies at the trust were put on hold for three months earlier this year while a review of working practices and shift patterns was carried out. When the Care Quality Commission visited in June it flagged a “compliance risk” with outcome 13 of the regulator’s essential standards. The trust’s latest board papers flag failing to maintain CQC compliance as a red risk. The trust is now recruiting to all vacancies.
In May the CQC visited NBT’s Frenchay Hospital in June. Unlike the visit to Bristol Royal Infirmary, which was a routine inspection, the Frenchay visit was in response to specific concerns about staffing levels and patient care. Despite noting that staff were extremely stretched the regulator found the trust to be compliant on each of the three outcomes considered during the visit.
North Bristol Trust’s difficulties addressing A&E performance must be considered in the context of an eventful year for the trust. Despite the performance issues the trust was designated a major trauma centre for the Severn region in April this year. The implementation of a new patient administration system at the end of last year has caused chaos in outpatients and theatres and required significant management and financial resource to address. A review of the implementation of Cerner’s Millennium criticised management for not recognising the scale of the change involved and not planning adequately for the switchover. This has had implications for performance against the 18-week referral to treatment targets. Chief executive Ruth Brunt left at the end of June after two years in post. She had originally been due to retire in April when permanent appointee Ian Cumming was scheduled to take up the post. However, in February he pulled out, and has since been appointed chief executive of Health Education England, meaning Ms Brunt stayed on until the end of June. She has been replaced on an interim basis by director of nursing Marie Noelle-Orzel. The trust’s interim director of operations Sue Watkinson also left at the end of June.
The trust has also been pushing ahead with its foundation trust application, although the original planned authorisation date of October has now been pushed back. The DH technical committee considered the trust’s application at the end of May but the trust does not expect it to leave the DH stage and be passed to Monitor until the end of the year. Although its management has always insisted the new £430m private finance initiative hospital currently under construction at the Southmead site is affordable the trust was named by health secretary Andrew Lansley as being one of 20 NHS organisations whose deals may prevent them from becoming foundation trusts.
Latest board papers describe the trust’s current financial position as “extremely serious” having already dipped into contingency resources earmarked for investment in change and restructuring of services over the next two years. Elective activity is 7 per cent a day below plan. The ongoing debate about the potential merger with University Hospitals Bristol also took a step up this year with the creation of a project board to formally consider whether one trust may be the best option for the city. An announcement is expected imminently.
A sustainable recovery
All three trusts are showing signs of recovery to varying degrees. University Hospitals Bristol achieved the target in June and is on course. Weston has been meeting and regularly exceeding the target consistently since April, reporting performance of 98 per cent in May. The trust has really focused on length of stay, increasing weekend discharge rates to 56 per cent of weekday discharges.
One senior source at Weston attributed the turnaround to the leadership of chief executive Peter Colclough, who joined the trust in September 2011, for bringing an increased and sustained focus to the issue. “Previously, we’d have a focus for a couple of weeks then there would be another fire burning somewhere else and we’d lose focus. This time we’ve kept the focus.”
Leadership, or a lack of it, has been blamed for the stubbornness of North Bristol Trust’s problems. A report due to go to South Gloucestershire Clinical Commissioning Group’s August meeting says there has been considerable clarity on what needs to happen to improve performance since February but identified the key “barriers to change” as “leadership and coordination, clinical leadership and trust-wide ownership of the performance problem”. Commissioners wrote to the trust at the end of June requesting further assurance that the trust is addressing the issue and a commitment that the trust will “sustainably achieve” national target performance by the end of September 2012. In a sign of commissioners’ frustration at the continuing failure to address performance a contract query has been raised (Bristol CCG performance report, August).
However, North Bristol’s new leadership seems to be having an impact already with performance in July pushing above 90 per cent for the first time in seven weeks. Actions taken include the setting up a weekly emergency access group attended by senior representatives from all directorates. This trust-wide approach is giving commissioners confidence that the issues will finally be addressed and the trust will meet its commitment to achieve a sustainable recovery by September.
Consistency, simplicity and length of stay are the system-wide priorities for ensuring lasting improvements. In October University Hospitals Bristol is to begin piloting a hospital hub at the Bristol Royal Infirmary which will see community health and social care staff based in the hospital to pull patients out. A similar programme of work bringing together the interested parties at UH Bristol is about to begin and could lead to a similar initiative being developed.
More longer term commissioners believe the detailed directory of services they are creating to support the new non-emergency NHS 111 telephone number will address some of the issues around fragmentation of community health and social care services. Although it is primarily a public facing service, clinicians and hospital staff will also be able to use 111 to find suitable services with capacity for patients ready to be discharged when it is launched in April 2013. Across the cluster the contract was awarded to Harmoni while out-of-hours services will also be delivered on a cluster-wide basis by Brisdoc, further reducing fragmentation.