'System approach' helps trust boost A&E performance by 40 percentage points

This spring the Royal Cornwall Hospitals Trust, which was placed in special measures last year, has seen a massive improvement against the four-hour waiting time target for accident and emergency patients.

In February, the trust saw only 56.6 per cent of patients within four hours at its type one emergency department at Treliske Hospital – the fourth worst performance in England.

Since then, the trust has implemented a “gold command” system, based on directors of Cornwall’s NHS and council meeting twice daily to drive improvement.

In April, the trust reported 94.1 per cent for its type one emergency department, a rise of 37.5 percentage points from February.

In the same period, the national performance rose by 5.4 percentage points.

Rab McEwan, chief operating officer at the trust, told HSJ that health economy leaders did a “hard system reset” over winter to focus on reducing overcrowding in the trust’s A&E.

From March, leaders of the trust, Cornwall Partnership Foundation Trust, Cornwall Council, Kernow Clinical Commissioning Group, primary and out of hours care, and the voluntary sector met twice every day.

The meetings replaced a “less efficient” escalation process that had seen the trust placed on OPEL 4 (black alert) for “87 per cent of the time” over winter.

In total, the group came up with 87 actions – including around six big changes and many small ones – to reduce overcrowding in Treliske’s A&E and improve patient flow throughout the system.

Among the more major changes were:

• Sending patients (delayed transfers of care) to 60 care home beds purchased through the Better Care Fund with Cornwall Council;
• Doubling the number of homecare providers from 20 to 40 and paying each homecare worker the national living wage;
• Bolstering the A&E department’s overnight cover with middle-grade doctors and advanced nurse practitioners; and
• Using consultants and GPs to increase the number of rapid assessments and streaming of patients.

Funding was provided from the winter pressures grant, which was awarded to trusts in last November’s Budget.

The trust also “suspended patient choice”, Mr McEwan said – which resulted in some patients being treated in beds further away than previously.

“We did a large communications exercise on this… about the fact our emergency services were under pressure and that we had to use all the resources that were available to us,” he said.

The trust has not been on OPEL 4 since the middle of March.

While the changes led to an improvement in A&E waiting times, Mr McEwan stressed that the trust has not got it “nailed or sorted”.

He said the improvements were a result of partnership work with the organisations that made up the gold command group and also members of NHS Improvement’s Emergency Care Improvement Programme team.

“The changes we’ve made are common sense and the right thing to do, and we’ve unpicked some things that weren’t right,” he said.

“Now the question is how do we sustain it going forward?”

He said the trust also needs to balance emergency work with its elective work, which was “pretty much suspended” during winter.

Mr McEwan said the trust cancelled 300 operations per month over winter. The trust also has one of the highest numbers of year plus elective patients waiting for treatment (234 patients at the end of April).

Last summer, the trust boosted its overall performance against the national A&E waiting time target after the CCG breached procurement law to enable the trust to take on responsibility for the county’s minor injuries units.