HSJ’s Local Briefing is our in-depth analysis of the major issues facing the NHS or individual health economies. Each week we publish a detailed report, examining the likely developments over the next four to six months. This week’s Briefing examines accident and emergency services at Barking, Havering and Redbridge University Hospitals Trust, specifically the A&E at Queen’s Hospital.

King George Hospital

King George Hospital, Iford. NOT FOR REUSE

King George Hospital, Iford. NOT FOR REUSE

Issue: Barking, Havering and Redbridge University Hospitals Trust has long had problems with emergency care. It is consistently one of the worst performing trustfor accident and emergency waits in England. However, trust level figures mask a variation between the two sites.

Context: In January the Care Quality Commission proposed something unprecedented in its damning post-inspection report: capping the number of patients who could be transferred from A&E to the “majors” area of Queen’s Hospital in Romford.

Outcome: HSJ can reveal the cap was never implemented, following an appeal by the trust. The CQC inspected the trust again last month and another report is due in July. It is expected to be just as critical as the one in January.

Workforce and structural problems at Queen’s

Barking, Havering and Redbridge University Hospitals Trust is the main acute trust serving outer north east London. It has two full accident and emergency units, one at Queen’s Hospital, Romford, the other at King George Hospital, Ilford.

Queen’s has trouble attracting enough emergency department consultants and middle-grade doctors, with locums often filling in for the latter.

Locums can have a more cautious attitude to discharge and admission and are thought to be part responsible for some of the delays.

The trust would not confirm what one source told HSJ, that it had only one consultant working after 5pm each day, but said it “carries out skill-mix reviews and has appropriate staff cover on every shift”.

The CQC report from January highlighted “inconsistent triage, poor use of the urgent care centre, a lack of accountability and effectiveness in bed management, discharges taking place late in the day, and long lengths of stay, largely driven by factors within the trust’s control”.

The A&E is one of the biggest in the country and the trust points out that Queen’s sees considerably more patients than it was designed for, also that the population is older than that served by King George Hospital.

Barking, Havering and Redbridge deals with roughly 56,000 emergency admissions a year – 36,000 at Queen’s and 20,000 at King George.

Queen’s is one of London’s hyper acute stroke units and houses the trust’s neurological unit.

The specialist beds mean that, relative to the number of admissions, Queen’s has fewer general beds to admit to than King George.

One insider said part of the problem at Queen’s was cultural: “The doctors are more engaged at King George.

“I would want to change the distribution of training grades, get more trainees, get more money to get people there for a couple of years.

“The dirty secret of the NHS is that when you get bad hospitals good clinicians don’t want to go there.”

The minutes of the trust’s March meeting saw the board agree “there was a problem with the leadership in the emergency department, a chronic problem that the trust had had for a long time”.

But a non-executive director, Maureen Dalziel, said the other directorates were at fault for “not see[ing] the four-hour access performance as their problem, they saw it as the emergency department directorate’s problem“.

One senior clinician told HSJ: “If it is perceived as solely a problem in the emergency department the wrong solution will be put in place.

“The emergency department clogs up because many in the hospital don’t think it’s their job to ‘pull’ patients out to the wards. This means patients waiting ages to be seen and ambulances queuing up outside.”

Significant additional resource has been poured into Queen’s with the unit receiving support from fellows in Lord Darzi’s clinical leadership scheme, 14 months of “reset” programme support from McKinsey and specialist length-of-stay software from consultant QFI.

Current performance

The full 2012-13 performance results have not yet been released by the government but an HSJ analysis indicates the trust had the lowest performance against the 95 per cent A&E target of any trust in England. Its weekly performance has been under 90 per cent for most of April, May and June 2013.

But the trust-level figures mask a significant variation between the two sites, with King George Hospital significantly outperforming the newer, private finance initiative-built Queen’s. Insiders said capacity issues and differences in clinical culture saw the older hospital outperform its neighbour.

Care Quality Commission intervenes

A CQC report in January found examples of poor but not unsafe care.

The report summarised the findings of unannounced visits in November and December.

These were to check Queen’s had addressed care and staffing concerns raised by earlier inspections in 2012.

The January report said people in majors requiring admission were waiting too long, with 5 per cent waiting more than 11 hours.

Others were nursed on trolleys when they needed to be moved into beds and the CQC concluded “there were not enough consultant or junior doctors in the A&E”.

The CQC said it proposed a cap on the number of patients who could be transferred from A&E to the “majors” area of Queen’s Hospital in Romford. The commission never gave a figure for the size of this cap. However, it said it was “designed to protect people from the risk of harm, and to give the trust breathing space to make the changes it needs to make”.

The legal restriction was intended to protect patients who were already in majors, the part of A&E dealing with medium acuity patients, who had been waiting too long, the CQC said.

The commission said a bottleneck there was causing major delays for patients. But concerns were raised about the pressure a cap would place on other A&E departments and the possible patient safety problems transferring patients might cause.

Response to cap proposal prompts a rethink

When the CQC said it intended to put a restriction on Barking, Havering and Redbridge’s licence, the trust instructed lawyers to challenge the decision.

If a trust does object, CQC procedure is for the evidence to be reviewed by another regional team within the commission.

The conclusion of this process saw the CQC’s original decision to cap attendances in majors overturned.

When asked on what grounds the trust made its appeal, a trust spokeswoman said: “We had concerns a cap might be impractical, but we fully accepted the need to improve our emergency department performance.”

The cap would have seen more pressure put on King George Hospital, Whipps Cross University Hospital and Basildon and Thurrock University Hospitals Foundation Trust, all of which already face significant A&E pressure.

Basildon has not hit the 95 per cent A&E target so far this year. Figures for Whipps Cross as an individual hospital site have not been available since it merged with Barts and the London Hospital Trust.

The impact on the CQC

The measure was the first time the CQC had attempted to cap attendances at an A&E. Although it must consider the effect of any restrictions it imposes, responsibility for dealing with subsequent capacity issues rests with providers and their commissioners.

One source within the trust pointed out that the problems at Queen’s should have been addressed by the local health economy before the inspection.

The CQC has indicated the appeal judgment would not deter it from placing a cap on other A&E departments if it felt that was necessary to protect patients.

Recent improvements

The trust gained a largely new management team in June 2012, including a new medical and nursing director.

In a statement, chief executive Averil Dongworth said the trust had managed to reduce its overall vacancy rate in A&E from 45 per cent to 18 per cent “in recent months”.

She added: “The trust is in discussion with a number of other teaching hospitals to create rotational posts to attract experienced consultants to the area.

“We have also been working extensively with staff in our emergency departments to improve morale, and subsequently recruitment and retention rates.

“With regards to our emergency access target performance, we recognise the need to make further improvements and keep performance on an upwards trajectory. We are in regular discussions and have an agreed plan with the Trust Development Authority and our clinical commissioning group partners.”

The trust could not confirm how much has been spent on McKinsey or the length-of-stay software from QFI.

The future

The CQC mounted another inspection on 21-22 May and its report is due to be published in July.

While the results are not yet known the trust’s published A&E performance since January suggests it could spell further problems for the embattled organisation.

One senior figure in the outer north east London health economy said: “There’s no reason to think the results will be much different to the last report.”

The medium-term position for the trust is further complicated by the planned downgrade of A&E at King George Hospital.

In 2011, then health secretary Andrew Lansley approved the decision by local commissioners to downgrade the unit.

He did this after the proposal was referred to him by the Independent Reconfiguration Panel.

Mr Lansley said he “accepted” the IRP’s conclusions but that “no changes will take place until the Care Quality Commission has assured the secretary of state that the services provided by Queen’s Hospital and other local health services are of a high standard.”