Essential insight into England’s biggest health economy, by Ben Clover

Safety

London Eye understands there are concerns at the highest levels about patient safety at one of London’s hospitals.

North Middlesex University Hospital has had well documented problems in its accident and emergency department since 2016, when the General Medical Council and Health Education England threatened to pull out trainees because of the lack of medium grade and senior cover.

Last July the Care Quality Commission said NMUH’s A&E unit had “turned a corner”, but it was still rated inadequate and soon afterwards its new chief executive was forced to resign because of a further deterioration in performance.

London Eye understands some of the serious incidents at the trust have worried system leaders, who think clinical leadership could be an issue there.

Since the start of 2016 the trust has had four medical directors. The current medical director, an interim, has been in post since the start of 2018.

Some of the serious incidents outlined in the trust’s most recent board papers are alarming.

A report about a death in A&E in February said: “Patient was checked into A&E. Patient was in the corridor for a long time, no observations were done due to no corridor nurse.

“The patient was sent for an X-Ray (and) the radiologist noted the patient looked unwell and patient was transferred to resus where the patient was diagnosed with a ruptured AAA. The patient passed away in resus.”

One of the disturbing things in this short account is the designation “corridor nurse”, which is not a recognised specialism.

The trust’s own investigation listed “increased waiting times in ED”, “lack of space or cubicle spaces to accommodate patients” and a “lack of medical staff to process work.”

In January a 15 year old boy had an orchidectomy that could possibly have been avoided after testicular torsion was missed in A&E. Sometimes things get missed in A&E and that’s unavoidable, but what’s potentially more damning is that he re-presented to A&E 17 hours later but left without being seen. He only got treated after his GP referred him directly to the hospital’s urology department.

The official data for January shows NMUH saw 75.5 per cent of patients in its A&E within four hours.

The trust also had a significant backlog of overdue serious incident investigations – 10 at the most recent count.

The organisation has started a series of “learning from never events” sessions, relating mainly to issues around surgery.

The continued problems at North Middlesex suggests systems for getting the appropriate workforce in place are not working well.

The trust commissioned Deloitte to look at how it paid for temporary staff and it is reviewing whether it should continue to use NHS Professionals as its sole supplier.

When NMUH’s A&E performance was considered a crisis situation in 2016, the system in London put out a call for medics to come and cover there temporarily. The offer was taken up in only very small numbers, London Eye understands.

The type one A&E performance for May 2018 was 75.7 per cent, which is a significant decline from the 83.7 per cent recorded in May 2017. In fact, it’s closer to the performance for May 2016, which was 72.9 per cent.

It’s worth remembering that the rebuilt NMUH was supposed to be taking the heat from closing the A&E at Chase Farm. It’s fair to say that has not gone well.

Changing forces

For a long time London trusts have quietly done quite well out of a finance rule called the “market forces factor”. This was an attempt by tariff-setters to reflect the higher costs of running health facilities in some parts of the country.

Obviously this did well by London, which is a bananas-expensive place to live.

The MFF could see trusts paid 10, 20 or 30 per cent on top of the tariff price for procedures. In more stable times this would encourage some home county commissioning bodies try and restrict patients from getting treated in London as it was more expensive.

Finance people in the capital are braced for changes to, or the possible scrapping of, the MFF. This would obviously be seriously bad news for the capital’s many specialist trusts.

Although superspecialist work is going to be paid mostly off-tariff by NHS England, London Eye understands the impact might still be significant. London trusts turnover roughly £1bn of non-London, NHS-funded work a year.

Finance people at some trusts are still dealing with the loss of Project Diamond funding, a scheme that used to top up London specialists for the complicated work they did.

There might be more news on this front soon.