North by North West: Skilling up the dinner ladies

Big Brother Success

To understand where the 44 sustainability and transformation plans for the English regions might be heading, take a look at Cumbria.

Because the STP process is very much a younger sibling to the Orwellian sounding “success regime” – which most of the county has been part of for the last year or so.

The regime has been overseen by NHS England, so it offers an insight into the kind of changes that are likely to be supported by national leaders.

And although Cumbria is right in the deep end of the financial crisis, many of its problems and potential solutions are likely to provide the necessary answers elsewhere.

One example will be the future configuration of accident and emergency services, with new and yet to be tested staffing models being developed by North Cumbria University Hospitals Trust.

The trust has a sky high vacancy rate of 40 per cent in the emergency medical teams, with the entire middle tier of overnight medical doctors at West Cumberland Hospital in Whitehaven staffed by locums.

Just three out of 11 consultant slots at the hospital are filled on a permanent basis, and the trust is haemorrhaging money on staffing agencies.

Something has to give, but local leaders do not see closing the emergency department – which is about 40 miles from the main unit in Carlisle – as a viable option.

To put it crudely, this means filling the rotas with staff who are less qualified, replacing consultants or middle grade doctors with nurses and paramedics who have received extra training to become “advanced clinical practitioners” and “physician associates”.

This could be a high risk strategy – the Royal College of Emergency Medicine has likened it to asking dinner ladies to teach a maths class – but Simon Stevens and NHS England clearly see the potential for it to safeguard key services in isolated coastal towns.

If it isn’t a disaster in towns like Whitehaven, then it might not be long before towns such as Barrow-in-Furness, Southport and even Blackpool are considering the model.

‘Unmatchable’ guidance

Meanwhile, hospital bosses in Chorley will have to implement an untested staffing model in a much tighter timescale.

The emergency department at Chorley and South Ribble Hospital was downgraded earlier this year due to the impact of the agency cap, and has been causing a major headache for leaders ever since.

Local campaigners, along with commissioners and Chorley MP Lindsay Hoyle, managed to persuade NHS Improvement to commission an independent review to determine whether Lancashire Teaching Hospitals Foundation Trust was really doing everything possible to reopen the department.

The review panel – which consisted of the medical director at County Durham and Darlington FT, a consultant at City Hospitals Sunderland FT and a matron at Wrightington, Wigan and Leigh FT – found there was “an opportunity” to reinstate the A&E on a 12 hour basis, rather than 24 hours as previously.

NHS Improvement summarised the report as saying “more could be done to open the department sooner” (the reviewers weren’t quite so clear) and after trying to recruit more doctors all summer, the trust will have found this difficult to swallow.

Chief executive Karen Partington has made it clear that reopening the A&E will require more staff to be recruited (which she has already tried to do), as well as a continuing reliance on the goodwill of current staff to work extra shifts.

In a similar vein to the proposals in Cumbria, the reviewers said the trust should move away from the recognised staffing model – requiring 14 middle grade doctors – to a solution involving GPs, nurses and associate specialists.

This reminds me of the “extraordinary” comments made by Jim Mackey earlier in the year, when he suggested that some royal college guidelines are “unmatchable” and effectively signalled a green light for exploring cheaper options.

Faced with the review findings, the trust has seemingly come to a compromise with NHSI whereby a 12 hour unit can reopen in Chorley, but only once a co-located GP led urgent care centre is fully in place.

GPs cannot run an emergency department, but having them on site will undoubtedly make the unit feel safer.

But I wonder if it wouldn’t make more sense to wait for the imminent consultation and reconfiguration of services between the trust’s Chorley and Preston sites.

A long term solution is needed, especially once you consider that Royal Preston Hospital is the major trauma centre for Lancashire. It should have 21 consultants to offer 24/7 cover, but it can’t get close to this and is currently running with a “derogation” from NHS England.

Legal threats

Efforts to draw a line under the Morecambe Bay scandals have prompted some worrying reactions from the Royal College of Midwives.

Last week, HSJ learned that the RCM had threatened legal action to prevent University Hospitals of Morecambe Bay FT from publishing a report into a payoff given to former maternity risk manager, Jeanette Parkinson.

The payoff agreement had allowed her to leave without facing an investigation by the trust into alleged poor behaviour, which emerged after investigations following the death in 2008 of baby Joshua Titcombe.

The RCM then issued a “threatening” statement accusing the trust of revealing details of a confidential agreement, saying it was “considering its options to pursue the trust”.

James Titcombe, father of Joshua, described the initial deal, the “attempt to keep it secret” and the subsequent statement as “immoral and wrong”.

The story has also brought questions for then HR director Roger Wilson, who now works at the Warrington and Halton Hospitals FT.

He told HSJ he was “extremely distressed” by the coverage and denied any impropriety. A spokesman for Warrington and Halton said it will be meeting with the Care Quality Commission next month to discuss the situation and whether Mr Wilson will be referred to a fit and proper person review.

Keep the GPs sweet

In Stockport, leaders of the vanguard project have revealed that their “multispecialty community provider” model is actually more of a “primary and acute care system”.

The MCP model is generally seen as being built and run by primary care, but as the King’s Fund has observed last week, problems have arisen because GP owned entities are not considered capable holding such large budgets.

It seems likely that Stockport FT will hold the new contract, as it can carry the financial risk and already runs community services.

The partner organisations will be desperate not to scare off the GPs, which is perhaps why they’re still calling it an MCP.

Remove from mailing list

Emergency care is high on the agenda in Greater Manchester, where leaders are concerned about the “extremely fragile” performance levels.

Jon Rouse, chief officer for the devolution team, has written to trusts to request their winter plans and assurances in order to demonstrate how the region as a whole will deliver.

Trust leaders already get bombarded with requests like this from national regulators, so let’s hope someone has remembered to take the GM trusts off the NHS Improvement mailing list.

Consolidate

Meanwhile, the pace of reconfiguration in Greater Manchester shows no signs of letting up, with another raft of services now added to the “standardising acute and specialised services” work stream.

These include paediatrics, obstetrics and maternity, cardiology, respiratory, orthopaedics, breast services, and gynaecology. For breast services and orthopaedics at least, there is likely to be some consolidation of surgical sites.

Council cuts

There was an interesting story in the Liverpool Echo, where the city council raised the prospect of the NHS stepping in to provide funding to prevent the closure of 17 children’s centres. The clinical commissioning group pointed out this would not be within its remit “as an NHS organisation”, but with the move towards health and social care integration, I reckon we’ll start seeing a few more stories like this.