Agenda item

In light of the recent announcement on A&E Services at Grantham and District Hospital, this item has been brought to the Committee as a matter of urgency by the Chairman, Councillor Mrs C A Talbot

 

(To receive a report from Dr Suneil Kapadia (Medical Director – United Lincolnshire Hospitals NHS Trust) which provides an update in relation to the provision of emergency care at United Lincolnshire Hospitals NHS Trust and the next steps to ensure continued patient safety and public engagement.  Dr Suneil Kapadia (Medial Director – United Lincolnshire Hospitals NHS Trust) will be in attendance for this item)

Prior to the consideration of this item, the Chairman welcomed Councillor D C Morgan and asked her to confirm her request to address the Committee as a Local member for Grantham.  Councillor Morgan indicated that she did not want to speak but had expected a paper which she had prepared to be made available to the Committee.  The Committee indicated that they were not in receipt of the document and, in order to clarify the best way forward, the Chairman adjourned the meeting at 10.25am whilst legal advice was sought.

 

At 10.35am, the meeting was reconvened where the following statement was made by the Chairman:-

 

          "I would like to remind everyone here that the purpose of this Committee is to scrutinise NHS Healthcare; and the Health and Wellbeing Board and their services and outcomes.

 

          It is essential that we respect this remit.  It is not for this Committee to criticise individuals or stray into matters that are the proper remit of other organisations, such as employment issues.

 

          Our job is to consider NHS healthcare services and their outcomes.  To that end we have invited a number of people to attend this morning's meeting to report on matters that are relevant to our work.

 

          It is not the convention of this Committee to allow members of the public to address this Committee unless they have been specifically invited to do so in advance.

 

          We have a very long agenda and it is important that Committee members have sufficient time to contribute to the discussion and take into account the comments of those people reporting to the Committee this morning.  I shall therefore not allow members of the public to speak.

 

          In accordance with Part 4 of the Council's Constitution, local Councillors have a right to speak at any Committee on a matter affecting their division and adjoining divisions.  I shall allow three minutes for a local member to speak.  This duration is consistent with the time allowed for councillors to speak in Full Council and for those who address the Planning Committee.  Statements will, therefore, need to be succinct and relevant."

 

Having sought legal advice during the adjournment, the Chairman invited Councillor D C Morgan to speak for three minutes to address the Committee on this item.

 

Councillor D C Morgan thanked the Chairman and indicated that she had not prepared an address but would highlight the main issues for Grantham residents, as noted below:-

·       Up until 14 August 2016, a patient in need of resuscitation was able to present at Grantham A&E at any time during a 24 hour period;

·       In the Grantham area, it was reported that there were 40 villages and 120k people, all of whom would no longer have access to emergency care overnight at Grantham A&E;

·       The situation had been monitored locally and it was alleged that at least three people had died in transit to other hospitals.  Although it was acknowledged that these patients may have died anyway, the Committee was advised that these patients were close to Grantham Hospital;

·       Further detail on these patients was provided to the Committee for context – a very elderly lady who had fallen and hit her head; and a gentleman who had suffered a heart attack and had a further heart attack in the ambulance in transit to Lincoln Hospital.  The concern was that lives were being held in the balance as a result of this decision;

·       Having analysed the papers presented, Councillor Morgan also alleged that, although these may be unintentional, some facts were misleading;

·       Councillor Morgan urged that the unit be reopened immediately.

 

The Chairman thanked Councillor Morgan for her address and referred the Committee to the report.  She expressed disappointment that the report presented appeared to replicate the Board papers of United Lincolnshire Hospitals NHS Trust.  The Committee was advised that the agenda pack presented for this item was larger than anticipated due to the number of embedded documents within the report from the Trust and this was to ensure that members of the Committee were in receipt of all information.

 

Consideration was then given to the report from Dr Suneil Kapadia (Medical Director – United Lincolnshire Hospitals NHS Trust) which provided an update in relation to the provision of emergency care at United Lincolnshire Hospitals NHS Trust and the next steps to ensure continued patient safety and public engagement.

 

The Chairman welcomed Jan Sobieraj (Chief Executive of United Lincolnshire Hospitals NHS Trust) and Dr Suneil Kapadia (Medical Director – United Lincolnshire Hospitals NHS Trust) and invited them to present the report which included:-

·       A timeline of actions leading up to and following the temporary closure of Grantham A&E;

·       The full collection of documentation associated with the change;

·       An early indication on the impact of this change; and

·       The next steps.

 

During July 2016, Lincoln and Pilgrim emergency departments expressed increasing concern as to their ability to fill their middle grade medical rotas.  Due to the increasing reliance locally, and demand nationally for locum doctors the fill rate of A&E shifts was reducing, thereby leaving departments at Lincoln and Pilgrim significantly understaffed.  The first week of August saw a further three middle grade doctors in Lincoln and 0.6wte at Pilgrim leaving the Trust which resulted in only 2.6wte middle grade doctors in Lincoln against an establishment of 11; and 4wte middle grade doctors at Pilgrim against an establishment of 11.  Despite mitigation and planning the rota could not be safely staffed.

 

The Trust Board was appraised of the situation on 2 August 2016 and presented with potential options.  The Trust Board was in agreement that the level of additional risk to patients as indicated by deterioration in ambulance handover times (particularly at Lincoln County Hospital); delays in first assessment; and a significant reduction in the number of patients assessed, treated and admitted or discharged within four hours (causing overcrowding within the emergency departments) was too great to continue without action.  Approval was given, therefore, to implement a temporary service closure at Grantham in order to support staffing at Lincoln and Pilgrim A&E departments.

 

The impact of the changes could not be underestimated on patients, stakeholders and staff.  It was stressed that the decision to reduce the opening hours at Grantham had not been taken lightly and was on the grounds of patient safety due to the lack of a viable alternative option.

 

An early monitoring process had been agreed and, between 17 August 2016 and 29 August 2016 indicated:-

·       Daily average attendances at Grantham was approximately 60 which demonstrated a reduction of 20 attendance per day on the average attendance (80) seen between 1 August and 16 August 2016 and was less than the predicted reduction of 25.  The daily peak in attendance was now being seen earlier in the afternoon which suggested a change in presenting behaviour.  There had been no increase in attendance at Lincoln or Pilgrim during this period;

·       Daily average admissions at Grantham were 12 in comparison to a previous average admission rate of 14 which suggested a daily reduction of 2 admissions per day.  This was less than the prediction of 6.  There had been no increase in admissions at Lincoln or Pilgrim during this period;

·       There had been no material changes in Out-of-Hours presentations; and

·       There had been no change in ambulance conveyance rates at Lincoln or Pilgrim although further data from EMAS was anticipated to analyse potential impact.

 

Early indications suggested that the expected impact was lower than originally thought although this would remain under scrutiny as it was acknowledged that the data only covered a 13 day period and was to be viewed with caution.

 

During these early stages releasing staff had provided 120 hours of middle grade support from Grantham to Lincoln A&E.  This equated to 16.5% of the Lincoln middle grade rota and was expected to increase over the coming weeks as the rotas settled.

 

Significant recruitment activity had been ongoing for a considerable period of time to increase the numbers of middle grade staff and included:-

·       All adverts had been reviewed and refreshed;

·       A new agency had approached the Trust and suggested they would be able to assist with the recruitment of consultants and middle grade doctors across hard to recruit posts and this was being explored;

·       The posts for Certificate of Eligibility for Specialist Registration (CESR) had been re-advertised;

·       A&E speciality doctor posts had been advertised with up to two sessions per week, together with funding, to support the completion of an appropriate part-time MSc or PhD.  This ULHT funded initiative had been developed in partnership with the Community and Health Research Unit  based at the University of Lincoln;

·       ULHT had arranged a stand at the Royal College of Emergency Medicine (RCEM) conference between 20-22 September 2016; and

·       A launch of a Masters programme for middle grade doctors was planned.

 

The timeline for the future was reported to include the following:-

·       Continue to review temporary arrangements with staff and partners;

·       Continue the implementation of the public stakeholder engagement plan;

·       Discuss at Member Locality Forums;

·       Regular system calls would continue to monitor the impact of these temporary changes;

·       Further quality assurance visits by NHS Improvement and the lead CCG would be completed;

·       The Trust Board would be briefed in October and November;

·       Suitable middle grade medical staff, in line with recruitment activities, would continue to be sought;

·       Temporary arrangements for Grantham A&E would be reviewed at the Lincolnshire A&E Delivery Board on 11 October 2016; and

·       NHS Improvement and NHS England to set a date, prior to the 17 November 2016, to review whether the temporary changes implemented at Grantham A&E could be lifted.

 

The Chairman stated that she had received legal advice on the powers of the Committee to refer the matter to the Secretary of State for Health in accordance with Regulation 23 of the Local Authority (Public Health, Health and Wellbeing Boards and Health Scrutiny) Regulations 2013.  The legal advice was complex but essentially stated that given the reasons for the Trust's decision on an urgent service reconfiguration on the grounds of patient safety, it would not be possible for the Committee reasonably to consider making a referral to the Secretary of State at this stage.

 

Members were given the opportunity to ask questions, during which the following points were noted:-

·       Meetings had commenced with the people of Grantham and the SOS Grantham group to keep them up to date with developments;

·       There was a clear need to ensure that the temporary partial closure worked as well as possible but it was stressed that all options would be given serious consideration as and when they were put forward;

·       The balanced needs of Lincolnshire residents and the patient safety of service provision was the driving force for this decision;

·       It was stressed that recruitment was ongoing but explained that even if appointments were made there was still a process to go through which was set out by the General Medical Council (GMC) which would include an English Language test for some applicants;

·       Some recruitment had taken place through locum agencies but the same process must also be followed for those staff;

·       It was suggested that the temporary closure may be extended after the three month period ended in November 2016 should recruitment efforts not enable a sustainable rota to be maintained;

·       It was reported that to appoint one doctor from an agency could cost in the region of £10k and that the number of those who could be appointed in this way was limited;

·       The retention rate was reportedly the best in the Midlands region but the Committee was asked to be mindful that this was an active market;  The reasons for staff leaving had not identified a trend and was due to a variety of reasons;

·       Staff morale at Grantham A&E was good and staff based there had indicated their feeling of increased pressure to deliver a service with the limited staff available.  It was reported that morale at Lincoln County Hospital was low due to the stresses involved in continually attempting to fill shifts.  The Committee was asked to note that Consultants based at Grantham had opted to continue to work there;

·       The Trust maintained regular contact with the East Midlands Ambulance Service (EMAS) and the Chief Executive of EMAS had indicated there were no significant patient safety issues as a result of the partial closure;

·       30% of A&E attenders were purported to be discharged with no treatment;

·       Service modelling had been done over a 24 hour period and it was apparent that patients were choosing to attend within the hours given;

·       Workforce modelling work continued as part of the Urgent Care work which was hoped to give a more practical solution, supported by GPs, for initial triage;

·       In order to accurately capture the impact of the partial closure, daily communication was taking place with stakeholders and data collected.  A full report would be presented to the Committee once collated;

·       The Committee expressed concern at the mixed messages given to residents from various healthcare professionals.  Although people are advised not to present to A&E or to their GP with minor ailments, advertising campaigns were encouraging people to seek advice no matter how minimal the symptoms were to enable early diagnosis of more serious conditions.  It was suggested that the advice for patients needed to be consistent and the system as a whole be considered and agreed;

·       Lincoln County A&E and Pilgrim Hospital A&E were similar in the services provided.  However, Grantham A&E had a range of conditions which could not be dealt with and patients with those conditions were always taken to another hospital.  This had been the case for a number of years.  This had been a source of frustration since the temporary partial closure of the unit, as the residents of Grantham were not aware that the services at this A&E department were extremely limited;

·       Clear criteria had been set out in a paper produced by Professor Sir Bruce Keogh, National Medical Director of NHS England, which suggested that any unit not meeting that criteria would be classed as an Urgent Care Centre rather than an A&E;

·       Road signage in Grantham indicated that the unit was an A&E department and it was explained that signage was not the control of the Trust;

·       A consultation with GPs had taken place prior to taking this action and the possibility of them working together to keep the unit open.  However, it was found that the GP community was not in a position to sustain this due to the shortage of GPs in the area;

·       All evidence of heart attacks showed that the chance of survival was increased if the patient was transferred to a specialist heart unit (Lincoln County) even if the patient was closer to another A&E department (Grantham).  Additionally, passengers involved in a train crash at Grantham would be taken to a major trauma centre (Nottingham University Hospitals NHS Trust or Lincoln County Hospital) as the rate of survival at these centres was greater;

·       It was stressed that the decision taken was an extreme measure in order to minimise the impact on patient safety but that the wider decision would absolutely take account of democratic processes;

·       The Committee was advised that Grantham A&E had never been a full A&E department and that the call to open it at this level would require a great deal of funding, infrastructure changes and increased specialist staffing.

 

RESOLVED

1.    That the Health Scrutiny Committee for Lincolnshire's support for the permanent reinstatement of overnight Accident and Emergency Services at Grantham and District Hospital be recorded;

2.    That the Health Scrutiny Committee for Lincolnshire's conclusion that it was not reassured that overnight Accident and Emergency Services would be reinstated at Grantham and District Hospital by 17 November 2016 be recorded, owing to the difficulty of recruiting suitably qualified A&E staff and a further extension to this temporary closure be anticipated;

3.    That senior managers from United Lincolnshire Hospitals NHS Trust be invited to attend the Health Scrutiny Committee on 23 November 2016 to provide a detailed report on:-

a.    The position with regard to the recruitment of Accident and Emergency staff across the Trust; and

b.    The impact of the temporary overnight closure of Accident and Emergency at Grantham and District Hospital on other NHS services.