Trusts in Surrey have consistently missed the four hour A&E waiting target, and attendance is rising. This briefing looks at how the economy will improve its performance.

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A and E struggle in Surrey

ISSUE: Failure to meet accident and emergency quality indicators in Surrey has been highlighted as a significant area of concern by commissioners, with trusts regularly breaching the four hour waiting target over the last 18 months.

CONTEXT: The county’s four main acute providers have reported year-on-year increases in A&E attendance, which are being translated into pressure on capacity. Efforts to control demand through community settings have so far failed to address the problem.

OUTCOME: Trusts have been forced to invest in extra A&E capacity, including additional beds and an expansion of their medical workforce. Most are also looking at fundamental redesign of their emergency care pathways and areas directly affecting it.

The issue

Failure to consistently meet the government’s target for 95 per cent of accident and emergency patients to be admitted, transferred or discharged within four hours is a long-standing problem for the Surrey health economy.

Despite the majority of the area being served by well established foundation trusts, good performance against the four hour target has been, at best, sporadic in recent times. 

Although this problem is not unique to the county, the fact the issue has affected three quarters of its acute providers has provoked the local primary care trust cluster into highlighting it as a significant area of concern.

The latest performance report, presented to NHS Surrey’s board on 20 July, warned that “quality performance issues remain of concern across the main trusts; most significantly acute provider attainment of the four hour A&E wait”.

The report acknowledged that its figures for the first quarter of the current financial year were derived from DH data that some providers were seeking to have amended “following the identification of issues in the information supplied”.

But, in spite of this, the document concluded: “In overall terms…. there is cause for concern about the levels of attendances and the volatility of A&E performance.”

Current performance

All acutes in the county have at times performed below par against the national performance measure during the second half of 2011-12 and into the first quarter of 2012-13.

April has been the nadir so far this year, with three acute providers failing to meet the target and the fourth scraping through by less than one per cent.

Surrey and Sussex Healthcare Trust has previously struggled most with the target, but has improved significantly of late.

Ashford and St Peter’s Hospital Foundation Trust and Royal Surrey County Hospital Foundation Trust have been the standout strugglers most recently. The two trusts failed to meet the target more often than they hit it during the first quarter of 2012-13 – both breaching it in seven weeks out of 13.

Ashford and St Peter’s

The £227m turnover trust is the largest provider of acute hospital services within Surrey, serving a population of more than 380,000 people at its two main sites.

Ashford and St Peter’s breached the target overall in 2011-12, achieving an average of 93.8 per cent for the year. Poor performance was most noticeable in the last two quarters of the year and this continued into 2012-13.

The proportion of patients treated inside four hours fell to 93.1 per cent in April, leading NHS Surrey to issue it with a contract query notice – subsequently revoked following improved performance at the beginning of May.

The trust moved on to manage 95.6 per cent for the first quarter as a whole, according to its June performance report. However, PCT documents reveal that this included a period of breach covering four consecutive weeks at the end of May and first half of June.

Relief at meeting the target at the end of the first quarter was apparent, prompting Ashford and St Peter’s chief executive Andrew Liles to begin his 26 July board report with the “really good news” and note that it represented “a lot of hard work on behalf of many individual members of staff”.

He did, however, mention the help the organisation had received from the national Emergency Care Intensive Support Team on work to redesign its emergency care pathway – work he said was “continuing as our top priority”.

“Achieving a long-term sustainable solution is what we are working towards, driven by our clinicians, and we are now planning a widespread communications and engagement campaign to reach staff right across our organisation during August and September,” Mr Liles said.

Some of the current work has focused “in particular on early senior clinical review throughout the 24-hour period, and a clear clinical plan for each patient”, June board papers from the trust note.

Mr Liles’ positivity was however tempered by comments made at NHS Surrey’s June board meeting, where it was noted “there was a lot of scope for poor performance between now and October”.

Royal Surrey County

The FT managed to meet the target in the final quarter of 2011-12 and for the year as a whole, which it noted was a “major achievement given the performance shortfalls on this measure in the early part of the year”.

“Given that this performance has been delivered against a backdrop of very intense winter pressures throughout the quarter, this is a fantastic achievement,” a board report stated.

The trust put last year’s success down to its collaboration and joint venture work with local GPs and community health and social services, despite an “incredibly challenging year” for A&E.

However, this level of achievement has not continued into 2012-13.

Like Ashford and St Peter’s, the Royal Surrey County also received a contract query from the PCT cluster due to its poor performance in April. It was the worst of any of the four main acutes that month, achieving an average barely above 90 per cent.

Early figures suggest performance may have improved in May and June, and that the trust was just about meeting the target. But the FT acknowledged in its May performance report that the poor figures for April make it “very unlikely that we will be able to deliver a compliant performance on this metric for Q1 as a whole”.

The FT serves a population of 320,000 with around 74,000 patients attending its A&E department in 2011-12. It has an annual turnover of around £232m.

Surrey and Sussex

NHS South East Coast’s annual report for 2011-12 picked out Surrey and Sussex Healthcare as facing “significant challenges in relation to achievement of the 95 per cent standard”.

Surrey and Sussex failed to meet the 95 per cent target at all between September 2011 and April 2012, leading to negative coverage in the local and national press. Its board papers note performance rarely rose above 90 per cent during that period and sometimes dipped below 80 per cent.

Board reports consistently highlighted problems with “capacity and flow of patients” through A&E and the rest of the trust’s main site East Surrey Hospital, which covers a population of 420,000 across east Surrey and north-east West Sussex.

The £193m turnover trust has been dogged by criticism from local patient groups and politicians about the closure in 2005 of Crawley Hospital’s A&E unit.

However, the organisation has seen a dramatic turnaround in performance during May and June this year, with high scores against the A&E target, of around 98 per cent for both months.

Trust chief executive Michael Wilson told HSJ he was “confident” Surrey and Sussex had now “turned the corner”, despite financial challenges including a £10m saving programme, and that future work was about “building up a level of resilience”.

Frimley Park

Frimley Park Hospital is perhaps the one acute provider in Surrey not feeling the heat quite as much on A&E performance.

Continuous significant growth in demand over the past decade has put a strain on Frimley Park’s emergency department. It was originally designed for 70,000 attendances each year. This number now stands well over 100,000. The trust has managed this increase with investment in front line staffing, in particular providing consultant delivered care including at evening and weekends.

The £265m turnover trust met the DH target overall in 2011-12, achieving an average of 95.8 per cent for the year, though board reports show it “dipped below target” in February.

This was against a background of continued year-on-year rises in activity, with the 1,726 more A&E attendees than in 2010-11

The trust, which serves a population of around 400,000 people across west Surrey, north-east Hampshire, and east Berkshire, achieved the same performance as in 2010-11, though the target in that year was 98 per cent.

It has also – just about – met the target in each of the first three months of 2012-13, although a PCT cluster report shows its figures were spoilt in April by performance slipping to 87.8 per cent for one week.

The causes of the problem

From a population point of view, the health of people in Surrey is generally better than the England average. Deprivation is lower than average and life expectancy for both men and women is higher than the England average.

However, Surrey does have a large older population. It has both “slightly more” people of 35 and over and “slightly less” at ages 10-35 years of age than England as a whole, according to its public health observatory Health Profile 2012.

NHS South East Coast noted in its last annual report that its trusts had “experienced a surge in attendances at times” during 2011-12 – up almost 4 per cent in the first three quarters of the year compared to 2010-11.

In addition, the strategic health authority highlighted “significant operational pressures” in January and February, from norovirus and ward closures, which had impacted on trust’s cumulative performance on the four hour target.

Chief executives confirmed to HSJ that a seemingly relentless increase in attendance was the key challenge facing their organisation’s ability to meet A&E targets.

Ashford and St Peter’s chief Andrew Liles said: “In a similar situation to other trusts, we have seen a year-on-year increase in the number of A&E attendances, particularly self-referred patients rather than those arriving by ambulance.

“This trend, combined with a longer length of stay on the ward for some of our elderly patients, has put increasing pressure on the whole emergency care pathway and made it difficult to maintain the four-hour A&E target.”

Michael Wilson, at Surrey and Sussex Healthcare, noted the same problem at his trust.

He said: “We are seeing substantial increases in activity. We’ve seen substantial increases emergency admissions and in GP referrals. We don’t know what’s driving that.

“I think we’re all seeing these types of increases right across the patch, particularly in Surrey.”

He said this was despite introducing alternative clinical pathways, such as walk in centres and a new range of ambulatory care pathways.  

He suggested that the 24/7 availability of A&E departments meant patients could fit healthcare in “when it suits them” compared, for example, to waiting for a GP appointment.

Plans to alleviate the problem

All the trusts are engaged in major programmes to improve or maintain performance, but are at different stages of progress.

Most are looking at improving their emergency care pathways and linked areas, such as short stay units, and seeking partnerships with other organisations. 

But, despite financial pressures and the national drive towards care in community settings, the majority are also now channelling funds into increasing A&E bed and medical workforce capacity. 

For example, Frimley Park’s 2011-12 annual report highlights the impact of the trust’s policy of “aiming to put more of the most senior doctors in the front line”. It currently has 13 A&E consultants, meaning a consultant is leading the department “seven days a week from 8am to midnight”.

Future performance also looks more secure than most. The trust opened the doors of a new emergency department on 10 July, which it has suggested is one of the best in the country. It features 25 rooms for “majors” and eight resuscitation bays.

Ashford and St Peter’s has recruited more A&E consultants and attempted to streamline its discharge process. As previously mentioned, it has also been working closely with the national Emergency Care Intensive Support Team to “improve the flow of patients through the emergency care pathway”.

Further changes are planned throughout the autumn to ease pressure on A&E.

Chief executive Andrew Liles said: “In particular these involve the introduction of a new emergency care pathway, and the redesign of our medical assessment unit and short stay unit. These changes, based on good practice elsewhere, should allow us to assess and treat more patients on a short stay basis and avoid unnecessary stays in hospital.”

Surrey and Sussex Healthcare is nearing the end of a £14m refurbishment of its A&E, which will see bed capacity increased by 30 per cent. It put an additional 40 beds in place in February.  

It also has plans to develop stronger partnerships with neighbouring acutes and community providers, building on existing arrangements for radiotherapy with Royal Surrey County and pathology with Brighton and Sussex University Hospital Trust. 

Surrey and Sussex chief executive Michael Wilson said the trust was also trying to adopt a more clinically led approach by “putting our doctors and nurses in charge”.

Meanwhile, NHS Surrey board papers note that Royal Surrey County took “remedial action” by opening an additional 22 beds and carrying out “root cause of every breach”.

A spokeswoman told HSJ the trust was investing in A&E to help it achieve the performance indicators in future.  

For example, it has established a clinical decision unit and an emergency assessment unit, and has invested in nursing staff in minor injuries and paediatrics, including emergency nurse practitioners.

The spokeswoman said the trust was also currently in the process of recruiting three additional A&E consultants and three new emergency medical assessment unit consultants to support the management of emergency care.

“[This will] further develop patient pathway links between A&E and the medical specialties under the umbrella of emergency care, [and] will assist the admission and discharge management of patients across the organisation,” she said. 

According to an SHA report from July, there is a “high level of confidence for immediate improvements” and delivery of the target in quarter 2.

The scope for success

Trusts that have already sought to increase clinical leadership on the A&E frontline and opened up more beds seem to be reaping the benefits. 

Frimley Park’s good performance appears stable while Surrey and Sussex Healthcare has seen a dramatic turnaround in recent months. It remains to be seen whether hints of improvement at Ashford and St Peter’s and Royal Surrey County can be built on.

However, the development of strong partnerships with clinical commissioning groups and community providers will be essential, as slowing the rise in attendance appears to remain the key goal to securing long term stability in A&E performance.