Essential insight into England’s biggest health economy, by Ben Clover

‘Apparently intractable cultural issues’ in A&E

They’re not the worst performers in London, but problems at two emergency departments show the kind of internal issues facing many in the capital.

North Middlesex University Hospital Trust in north west London hit the national headlines a few years ago over chaotic scenes in its accident and emergency.

An investigation by the General Medical Council and Health Education England saw the latter threaten to pull out its trainees.

An appeal went out for other trusts to supply middle-grade and senior clinicians – but take-up was very low. Considering all the attention and management support it has received in recent years, you might hope NMUH’s A&E would have turned a corner.

And its February results against the four hour target weren’t too bad – its performance was 82.4 per cent against both all-type and type-one attendances. On the latter this was only 2.6 percentage points behind the national average, and on type-one this is comfortably ahead of the (disastrous) national score of 76.9 per cent. The trust improved its performance on both measures by 0.1 percentage points compared to the same month in 2017.

But detail in a recent board paper is worrying.

A board committee said the national target of getting to 95 per cent performance by March 2019 was “extremely challenging” and agreed to aim for that score by August 2019 instead.

It notes “this has been a significant feature in recent regulatory discussions”.

A&E activity has gone up across London and by 8 per cent at NMUH, but that does not satisfy senior leadership at the trust as a reason.

The board report said: “The committee expressed its continued concern as to apparently intractable cultural issues within the department and requires assurance as to the necessary HR and OD [organisational development] interventions being in place to break this cycle.”

What issues does it mean?

Well, a consultation on middle-grade medical rotas is underway – and this is rarely a sign that they’re currently configured to the satisfaction of bosses.

The trust has also appointed a sickness review board – sickness absence was reported to have particularly hurt performance in February.

Across the trust as a whole sickness absence has increased from 3.76 per cent to 4.56 per cent year-on-year.

Barnet Hospital’s clinical director has been seconded to North Mid (Barnet is part of the Royal Free London Foundation Trust, whose chief executive Sir David Sloman is also the accountable officer for NMUH), and a restructure of the management of the department was implemented on 8 February.

Meanwhile, considering that senior medical cover and support was such an issue in 2016, reports of a recent death at the hospital are also concerning.

A separate report to the board said non-invasive ventilation had been removed by a junior doctor from a lung cancer patient admitted out-of-hours with respiratory failure. “This had been the wrong decision and this had been corroborated by the coroner’s report,” it said.

The then medical director wrote to all consultants “to ensure that there was adequate consultant support to the junior teams overnight”.

‘Organisational authority’ in south London

Reviewing how A&E rotas are configured seems, surprisingly, to have only recently become a topic of interest for trust boards. King’s College Hospital FT has asked NHS Improvement for £1-2m to change the way it organises and remunerates the staff in its Denmark Hill A&E unit.

Interim chief operating officer Shelley Dolan noted, when introducing the proposal to the FT’s February board, that it had been set up on a five-day model that took insufficient account of patients arriving during evenings and weekends. 

Further south, St George’s University Hospitals FT has seen falls in A&E performance of around 7 percentage points year-on-year on the type-one and all-types measures.

This prompted a visit from NHS Improvement’s emergency care team who made one particularly telling comment (alongside a 15-point action plan).

Noting that staff did not prioritise the four hour standard, the inspection report said: “The site [management] team does not currently have the organisational authority to hold services to account.”

It said the team focussed instead on avoiding 12-hour breaches, which is not unreasonable. But the fact management could not manage the unit is clearly a bad sign.