North by North West: Funding still pending as new hospital opens

GM still thrashing out major trauma

Salford’s new major trauma centre is finally due to open this month, more than a decade after plans for the service were first drawn up.

Most of those years were spent navigating the extreme fog of the NHS capital funding system (the scheme has cost more than £75m). Then last year’s planned opening was postponed due to difficulties with financial arrangements and nailing down patient pathways.

The pathways have long proved contentious, stretching back to the original decision to site Greater Manchester’s major trauma centre at Salford, instead of Manchester Royal Infirmary.

Although just 20 minutes apart, the hospitals are of course run by different trusts – the Northern Care Alliance and Manchester University FT – where rivalries have been fierce.

The compromise struck at the time, driven by Salford’s specialist neurology service, was that Salford needed to take all head injury cases and have the official MTC designation, but MRI could get cardiothoracic (heart and lung) cases.

Most trauma specialists will say it’s far from ideal arrangement.

Things then get complicated with vascular services, which MUFT runs for the whole GM, but where input will frequently be required in head injury cases.

An NCA spokesman said vascular specialists from MUFT will attend the Salford site where needed, including performing surgery, which likely accounts for some of the financing difficulties.

It clearly isn’t all sorted out though, as recent integrated care board papers note ongoing talks concerning £13m of recurrent costs associated with the major trauma centre.

That’s a huge amount of money to lack clarity over, especially when the NCA has just reported a deficit of around £70m.

The ICB paper noted how it “continues to work [to] ensure that appropriate costs are being incurred based upon an evidence base of requirement”, while the latest NCA papers say it is “assuming” in its 2024-25 plan that major trauma services will be “fully funded”. So that could get interesting.

Avoidance strategy

The North West has made good progress in treating the longest elective waits in the last six months, particularly in Greater Manchester.

But much of the progress on 65 and 78-week cases has come with help from external providers, with both GM and Lancashire among the major users of private capacity, when adjusting for total activity volumes.

Several sources told NxNW that financial concerns will squeeze the activity being outsourced, and limit the amount of further progress that can be made.

That’s a concern because the underlying picture on electives still looks quite bleak.

The North West has by far the largest waiting list, with almost 14 cases per 100 of the population (England average is 12), along with the joint highest median wait time, and the second highest proportion of 52-week waiters.

On a value weighted-basis, its activity levels compared to pre-covid are the second lowest of the seven regions.

Given the financial screws are tightening, the region will need to find other ways to plough through those lists, or even better, to avoid patients being added to the lists altogether.

The data suggests there is major scope on the latter, with all three systems making relatively light use of specialist advice from hospital consultants to GPs.

This is something NHS England has been pushing hard, with the national body boasting that trusts will have used specialist advice to avoid more than 2.2 million referral-to-treatment pathways in 2023-24, which is up from around 600k in 2019-20.

That’s a 250 per cent increase nationally, while Lancashire reported an increase of just 84 per cent over the same period. GM and Cheshire and Mersey were also below average, with 180 and 200 per cent increases respectively.

As well as the below-average increases, NHSE’s stats also suggest all three systems lag the national average in terms of RTT cases avoided, with Lancashire trailing far behind.

Although the stats say nothing about the quality of those avoidance decisions, it will be worth assessing whether more could be done to make GPs aware of the specialist advice option, to process the requests, and possibly even to shift more risk to primary care.

When approached by NxNW, the ICBs were more concerned with trying to quibble with the data than engaging with the issue, although GM did acknowledge it’s working to ensure faster turnarounds for requested advice, higher quality responses, and training and education for the relevant clinicians.

Trust reviews 400 paediatric cases

Around 400 paediatric cases are set to be reviewed at Stepping Hill Hospital after concerns emerged about the quality of its audiology testing.

It comes after a recent peer review, which had been instigated last year after NHSE cited serious failings with some paediatric audiology services.

All babies born in the UK should have a routine hearing test to identify those at risk of hearing loss, with these babies then referred for a specialist screening.

But after problems with the quality of these tests emerged in Scotland, meaning hearing loss went undetected in some cases, NHSE ordered local leaders to review services in England.

It’s not exactly clear what the issues have been at Stockport FT’s Stepping Hill, but the trust said it has recently introduced new operating procedures, updated its policies, and refreshed the training courses for its audiology clinicians. The 400 cases being reviewed are the total number of cases seen by the service over the last five years.

Warrington and Halton Hospitals was one of several trusts NHSE initially identified as having troublingly low diagnosis rates, and its service was forced to close temporarily last year. The trust found it was using outdated decibel thresholds for its tests, which have now been adjusted.

This means deafness may not have been identified in some children, who then would not have received the support they needed around language and communication, which is crucial for their development.

Difficult bullet to bite

Leaders have long shirked the challenge of consolidating neonatal crucial care units in the North West, many of which fall a long way short of the recommended activity thresholds.

But as predicted last year, closer attention is starting to be given to the current configuration.

A report to Greater Manchester’s commissioning board this month noted how the local neonatal unit at Tameside General Hospital has reported fewer than 500 bed days in each of the last three years, against a minimum standard of 1,000.

It added: “Further work is required to review Tameside LNU activity and the level of care able to be provided for neonates.”

Similar work will need to happen across the region, with several units, including the LNUs at Chester and Ormskirk, also falling far short of the standards.

This is an extremely difficult bullet to bite, given that maternity services rely on neonatal critical care being on site.

But that’s what integrated care systems were created for, isn’t it?

Out-of-trouble?

Demand growth and a lack of community care have been officially slated as the reasons for Greater Manchester’s huge growth in out-of-area mental health placements.

But the surge – which has massively outstripped OAPs reported by other systems – also came right after 60 forensic beds were closed to new admissions following the abuse scandal at the Edenfield Centre.

In theory, this should not have impacted on reported OAPs, as forensic cases are treated separately, but well-placed sources told NxNW they’ve had a significant indirect impact.

Apparently, some patients who would normally have been placed in medium-secure units (such as those closed at Edenfield) have been placed in low-secure facilities instead, which has then pushed some cases normally referred to LSUs into general acute or PICU beds.

Leaders tend to be coy about this sort of thing – it could clearly pose some serious safety risks if forensic patients needing secure care are not being placed in appropriate facilities.

Greater Manchester Mental Health Trust acknowledged some patients awaiting LSU beds were being placed in PICUs, but suggested this was part of a normal care pathway where appropriate safety measures are put in place.

The fact the system felt able to suspend referrals to Southern Hill Hospital in Norfolk, its largest provider of out-of-area placements, does suggest more capacity is becoming available.

Additional PICU beds are due to open imminently in north Manchester, while the Edenfield units are also due to reopen at some stage.

Faulty alarm closes hospital for days

Mid Cheshire Hospitals is one of the lucky trusts to get into the first wave of the new hospital programme, with a full rebuild of its main Leighton Hospital site.

It’s even expected to be one of the first projects to break ground, after being selected as a test site for the standardised Hospital 2.0 concept. There’s perhaps something to be said for accepting national leaders’ demands at an early stage, and not trying to squeeze out more money.

But the project won’t do away with all the trust’s estate problems, as much of its secondary site, Victoria Infirmary in Northwich, is more than 120 years old.

At the end of April, the hospital’s rather antiquated fire alarm system began sounding and couldn’t be switched off, causing a whole host of outpatient appointments, day cases, and minor injury services to be moved to Leighton. Because the repairs and spare parts weren’t available over the weekends, the site was completely out of action for several days.