'To say there is no overall clinical vision is a bit harsh. ' So says David Highton, chief executive of Oxford Radcliffe Hospital trust. Harsh perhaps, but many believe that the comment on the state of the trust's accident and emergency services, which originates from a regional investigation, is fair.
The trust drew up an action plan, seen by HSJ, following a visit by South East regional office, the National Patient Access Team and the Department of Health's winter and emergency services team in January.
The plan, dated 18 January 2001, lists the key problems identified by the regional investigation which questioned the viability of some of the trust's services and identifies problems in clinical leadership and management.
The regional report claims that there is 'no overall clinical vision for emergency services' and criticises the medical rota for not being 'focused on emergencies' but on specialties and academic work. The post of medical director has not been filled following the resignation of Dr Chris Bunch last year.
Mr Highton told HSJ that the remit for the post was currently being consulted on and, once agreed, would be advertised.
The regional report also criticises the fact that the newly established medical assessment unit is being regularly used as a medical admissions ward.
Set up last October to try to relieve some of the pressures on A&E by taking medically referred patients from GPs, the unit itself becomes blocked and closes, the report suggests, putting pressures back on A&E.
Fault is also found with the trust's escalation policy, designed to filter patients elsewhere as capacity is neared. The system fails to predict increases in pressure and is triggered too late. 'It is reactive, not proactive, ' says A& E consultant and clinical director Philip Hormbrey. He adds that the department regularly reaches level three - capacity - by the middle of a Monday morning.
With all these pressures it is little wonder the staff are getting fed up. Mr Hormbrey told HSJ: 'We are losing all the top people: our senior nurse resigned last week.
We have lost two senior house officers with stress-related illnesses, and one registrar resigned due to the danger of the department. The nursing staff are fantastic. They work their hardest, but they have taken the brunt of these pressures and they are resigning week on week.
'I regularly tell all our management team that the department is unsafe. I have notified the General Medical Council that the department is not safe, with the knowledge of my management team. I have written to the postgraduate dean to say the department is an unsafe place to train senior house officers and registrars. '
Oxfordshire community health council is concerned about difficulties replacing lost staff. Deputy chief officer Val Garner says she is concerned that senior nurses are being replaced by staff with less experience.
Mr Hormbrey believes that managers at the trust recognise the difficulties but that they too are 'totally overworked'.
'We believe we have a very supportive management structure trying to deal with the situation and create beds. '
He believes that there are 'solutions in the trust that could be achieved with adequate beds and better use of beds'. But one 'solution' has raised eyebrows: councillor Margaret Hodge, chair of the CHC acute hospitals working party, says: 'The recent initiative to have St John Ambulance volunteers helping in this regional trauma centre does fill us with some concern. '
Staff in the A&E department have been in collective dispute with trust managers for about a year. 'It has been about staff persistently and consistently reporting concerns through formal means and informal means, ' says Royal College of Nursing regional officer Tim Curry.
The main points made by staff and the conclusions reached last September, by a staff panel that included two external assessors, closely echo the problems identified in the trust action plan.
Although the RCN has not had sight of that plan, Mr Curry says the similarity of content comes as no surprise.
'These things have been raised by staff for over five years. 'He says that some of the panel's recommendations were 'fairly long-term and are going to take the trust a long time to turn around' - nurse recruitment and retention, for example - 'but there are more simple things that could be addressed'.
Mr Highton says the trust is working to recruit therapists and pharmacists to cover weekends to ease bottlenecks. In addition, the successful intensive community support service operating in some areas of the county is now taking referrals at weekends as well as weekdays.
The regional report also suggested that Oxfordshire health authority was not sufficiently engaged in the problems of its A&E ward and that there are 'too many meetings - not enough finish dates'.
Oxfordshire HA deputy chief executive Andrea Young says the comments about the authority's lack of engagement came as a 'surprise'.
'We have given quite a huge commitment to the Oxford Radcliffe in terms of management support and in terms of investment.
'Funding levels of emergency care this year are well in excess of£1m. ' However, she welcomes many of the suggestions in the action plan as 'worth pursuing'.