North by North West: Merger ‘kicked into long grass’ amid warring departments

Leaders in Liverpool spent several years making the case for merging the city’s two acute hospitals, with Liverpool University Hospitals Foundation Trust finally being formed in 2019.

The primary argument for merger always centred on the consolidation of around 20 specialties duplicated at both The Royal Liverpool and Aintree hospitals, with the creation of single services expected to deliver the holy grail of improving care whilst also saving money.

A poster child for the new single services – as highlighted publicly by the trust – was gastroenterology, and this was one of the first specialties where integration work began.

But last year it emerged there were high tensions between the two departments, with staff at The Royal furious at having to inherit several thousand follow-up cases which had seemingly been hidden on Aintree’s IT systems.

This led to a whole array of accusations flying around between the departments, an external review being commissioned, and mediation sessions being organised last summer.

This doesn’t seem to have worked, however, as multiple staff have told NxNW the merger of the departments has been suspended, with each hospital maintaining a distinct clinical director for gastro services. The official line is the departments will still merge, but staff say it’s effectively been kicked into the long grass.

This may well be the sensible thing to do, but does show just how hard service integration can be, even within the same statutory organisation.

Site-based leadership

There are multiple other specialties, such as vascular and emergency general surgery, which are still ploughing on with consolidation, and which will need to be carefully managed.

Some senior staff believe the new ‘site leadership’ model introduced by interim chief executive Sir David Dalton, which mirrors the model used by his former trust, the Northern Care Alliance, is not conducive to integration and instead serves to emphasise divisions between the hospitals.

One senior clinician said: “The single site leadership model has not really helped as now the tendency is for people to go back to silo working with less pressure to co-operate over the two sites.”

Site-based leadership is arguably the best model for stabilising services and getting a grip on the trust’s serious quality and performance problems, but does it come at the expense of integration?

Staff exodus

Meanwhile, serious concerns have been mounting around a specialist service within gastroenterology.

As previously reported, a controversial tender process has resulted in surgical care for intestinal failure being removed from LUHFT, with cases sent to Salford Royal in Greater Manchester instead.

The idea put forward by Salford, and accepted by former directors at LUHFT, was that Liverpool would then be a regional centre for non-surgical intravenous feeding services (known as ‘home parenteral nutrition’) – and take these cases from Greater Manchester.

But NxNW understands that since the outcome of the tender was announced, all three of LUHFT’s fully trained intestinal failure consultants have now left the trust, leaving the HPN service looking untenable.

Although the three consultants were medical, they would play a crucial role in keeping patients alive before and after surgery, and the loss of surgical patients essentially removed the most interesting and fulfilling part of their job.

Over the last few months there has been a scramble involving LUHFT, Salford and NHS England to try to come up with a plan to keep HPN care going, which has resulted in the service being maintained by one gastro consultant at Aintree Hospital, who is not formally trained in intestinal failure and also has duties as a clinical director. The trust insisted the consultant has “extensive experience” in managing HPN and nutritional services, and that patients are also supported by a specialist nursing team.

However, sources said there has also been a reduction in specialist nurses and support staff.

‘Reframing the narrative’

It is difficult to see these changes as representing anything other than a major downgrade to HPN care in Liverpool, just when it was supposed to be built up as a regional centre.

Frantic efforts to recruit or upskill more consultants have so far come to nought, with internal NHSE documents seen by NxNW saying the trust needs to “work to improve the language/presentation of the current situation” and set about “reframing the narrative to produce a compelling vision of what the Liverpool service will look like as part of a [North West] network”.

In a statement, the trust said: “We are continuing to work together with partners to support the ongoing provision of safe HPN services for our patients.”

NHSE said it was working closely with the trust and is assured appropriate action is being taken.

Value for money?

Much was made earlier this month about North West Ambulance Service ending a temporary £3m annual vehicle cleaning contract put in place for the pandemic.

The Manchester Evening News said crews were furious about the contract ending, as they would have to go back to the pre-covid situation of cleaning the ambulances themselves. This would mean more IPC breaches, longer turnaround times, and a further blow to morale, they said.

But even if the temporary covid funding was extended by the government (which it wasn’t), would continuing the contract have been a good use of resources?

Not all emergency departments had the external cleaners on hand, and NxNW understands comparative results of infection prevention audits suggested ambulance crews were cleaning their vehicles just as effectively as the external company.

While there might now be a slight increase in handover-to-clear times, these are currently below the 15 minute target for NWAS. As mentioned in previous editions, NWAS’s real problems are with the arrival-to-handover times, which are way above 15 minutes.

Ongoing service suspension

A review of maternity services at East Cheshire Trust has offered up the expected answer: that there aren’t enough anaesthetists to safely restart obstetric care.

The suspension of obstetric care at Macclesfield hospital at the start of the covid pandemic was always supposed to be temporary, but several proposed reopening dates have now been missed.

A report to the trust’s board in March said: “In essence the anaesthetic consultants no longer believe it is safe or desirable to re-instate obstetrics until the anaesthetic workforce is capable of bringing the service closer to the standards supported by professional bodies.

“In the current context of workforce constraints in anaesthetics, the temporary suspension of intrapartum care has positively improved middle grade anaesthetic cover in critical care. This alongside the recommendations of the Ockenden report (which looked into care failings in Shropshire) has informed the risk assessment…”

The report adds there would need to be a significant increase in investment and staffing to bring back obstetric care, which would “need the support of commissioners, system partners and regulators”.

But even if more investment and anaesthetists can be found, will there be any other staff left? Despite continued efforts to recruit, the department’s vacancy rate is now a massive 30 per cent.