Agenda item

Grantham Hospital Accident and Emergency Department: Outcome of Referral to the Secretary of State for Health

(To receive a report from Simon Evans (Health Scrutiny Officer), which asks the Committee to consider the determination of the Secretary of State for Health on the overnight closure of the Grantham Accident and Emergency Department; and the latest information from United Lincolnshire Hospitals NHS Trust regarding their staffing levels for emergency care.  Jan Sobieraj (Chief Executive of United Lincolnshire Hospitals NHS Trust) and Dr Neill Hepburn (Trust's Medical Director) will be in attendance for this item)


The Chairman welcomed to the meeting Jan Sobieraj, Chief Executive, United Lincolnshire Hospitals NHS Trust and Dr Neil Hepburn, Medical Director, United Lincolnshire Hospitals NHS Trust.


The report presented advised the Committee that on 2 August 2017, the Secretary of State for Health had issued his decision on the referral of the overnight closure of Grantham Accident and Emergency Department, which had been submitted by the Health Scrutiny Committee for Lincolnshire in December 2016.  It was reported that the Secretary of State for Health had accepted the advice of the Independent Reconfiguration Panel (IRP) that the referral did not merit a full review and should be resolved locally.


Detailed at Appendix A to the report was a copy of the advice received from the IRP; and Appendix B provided a copy of the letter from the Secretary of State for Health to the Chairman of the Health Scrutiny Committee for Lincolnshire, dated 2 August 2017.


The Committee was asked to consider the determination of the Secretary of State for Health and consider what next steps should be taken with regard to 'further local action by the NHS with the Council to address the issues raised; and to consider the latest information from United Lincolnshire Hospitals NHS Trust, regarding their staffing levels for emergency care'.


The Chairman also welcomed to the meeting Councillors L Wootten (Grantham East County Councillor) and R Wootten (Grantham North County Councillor), who had made a request to the Chairman to address the Committee regarding this item.


The Chairman advised that he proposed to allocate the two Councillors three minutes each to address the meeting, following which the Committee would receive an address from the Trust.  The Committee was advised further that the Chairman was then proposing to allow one representative from each of the patient groups present three minutes to address the Committee.


Both of the Grantham Councillors in their address to the Committee expressed the concerns of local people in and around Grantham who were furious about the down grading of the Accident and Emergency service they had been receiving, and to the fact that one year on, there was still no plan to reinstate overnight services at the Accident and Emergency Department.  It was felt that the reduced service was causing local people extra stress and was also putting them at risk.  Some concern was also expressed regarding the United Lincolnshire Hospitals NHS Trust being placed in 'financial special measures'.  In conclusion, the Health Scrutiny Committee for Lincolnshire was asked to do all it could to help resolve the situation for Grantham residents.


Some members of the Committee echoed the concerns of the two divisional councillors; and one member felt that there needed to be an open and honest conversation regarding the options for future emergency care delivery at Grantham Hospital; and that wider consultation needed to be undertaken with the Council.


The Chief Executive, United Lincolnshire Hospitals NHS Trust advised that the Independent Reconfiguration Panel report had stated that 'Commissioners must as a matter of urgency work with the local providers (including mental health care and community providers as well as ULHT) and the HSC to engage and consult the public across Lincolnshire on current services and what might be achievable and sustainable in the future'.  It was stressed that ULHT had a role to play, to support the CCGs.


The Committee was advised that ULHT had not recruited sufficient staff during the year, and at the moment the service was very fragile.  Appendix C to the report presented provided the Committee with details of the current position with regard to the Emergency Care Service. 


The Medical Director, United Lincolnshire Hospitals NHS Trust advised the Committee that hospital emergency departments were staffed by a combination of consultants, middle grade doctors, doctors in training, A & E nurses and emergency care practitioners.  The Committee was advised further that current guidance was for there to be an onsite presence, by a consultant, for 16 hours per day.  Tables 3 and 4 on pages 41/42 of the report provided information relating to the number of funded medical posts, the numbers in place in August 2016 and the rostered presence of senior medical staff for the three A & Es.


It was highlighted that an agreement with commissioners, NHS Improvement and NHS England was that the A & E Department at Grantham and District Hospital would return to 24/7 opening hours when the required middle grade establishment had been reached, and that there had not been any deterioration in the number of consultants.  The number of middle grade doctors had been set at 21 substantives/and or long term locums, against an establishment of 28.  It was highlighted that middle grade staff were the back bone of the service. The model of provision would enable three 24/7 rotas to be staffed consistently and safely, however, there would still be a requirement for agency staff support to fulfil all duties within the rotas.  Table 4 on page 42 summarised to the Committee the medical presence required for each of the ULHT Emergency Departments.


The Committee was advised that nationally, there was a shortage of A & E staff.  It was reported that two more middles grades had been appointed, but they would need four months on the junior rota before they could participate on the middle grade rota.


It was reported that the total number of substantive consultants in A & E, had been increased to five from August 2017, with a new appointment.  However, due to some ill health, this had reduced the expected consultant staffing numbers for ULHT from 15 wte to 14 wte during May – June.  It was highlighted that the A & E Department at Grantham Hospital had 2.5 registered nursing vacancies.  Table 5 provided the Committee with a summary of recruitment to medical middle grade posts for the three ULHT Emergency Departments.


The Committee was advised that the Trust was coming up with initiatives to train and upskill middle grade staff to consultant level.  It was highlighted that the Trust was also looking at changing the way A & E worked as data had suggested that A & E was mainly being used by elderly and frail patients, needing assessments and not a traditional A & E service. 


The Chairman invited the Patient Group representative to address the Committee for a period of three minutes.  The Patient Group representative echoed what had already been said by the two Grantham Councillors and expressed concern that the ULHT had not taken on board the impact on the residents of Grantham.  A request was also made for an honest and open discussion with ULHT and the CCG concerning future provision for Grantham.


During discussion, the Committee raised the following points:-


·         What proposals were going to be taken forward by the Trust to offer a solution to the problem of providing 24/7 provision; whilst maintaining patient safety.  The Committee was advised that the starting point was how to get back to 24/7 provision.  To do this discussion would be had with the CCGs and then consideration would be given to changes to the type of staff needed within A & E, for example having an 'in-reach' approach of general surgeons and orthopaedic surgeons, supporting the core staff; this would be more responsive to the health care needs in the community, such as more frail elderly patients.

·         Better communication with the general public on what was proposed across Lincolnshire as a whole; and how the general public access health services, whether that be GPs, Out of hours, and the 111 provision.  It was felt that communication was key to ensuring success; and also to building up trust within the community.  It was also felt that it was essential to ensure that sincere consultation with the wider public was ongoing to ensure that they had input into any proposed changes going forward;

·         Encouraging patients to use GPs and Pharmacies more;

·         The need to encourage young people to look for careers in the health service at an earlier age, by using career guidance through schools;

·         One member advised that Louth had previously experienced a similar situation to that of Grantham, as Louth Hospital no longer had an A & E Department;

·         One comment made suggested that evidence had suggested that there had not been a problem with the overflow to Lincoln.  It was felt that the model across all three sites was important to Lincolnshire as a whole.  Confirmation was given that prior to 2016, trauma cases had not been taken to Grantham A & E, and most had gone to Nottingham.  It was further highlighted that a whole system solution was required to change the way services operated to ensure that the patient was dealt with at the right time and at the right place.  It was essential to get services joined up in their thinking and operating;

·         One member expressed concern of the long waiting times for ambulances in some instances.  It was felt that the ambulance service needed to be included within the joined up thinking approach;

·         Confirmation was given that until staffing levels were at the required levels, health and safety prevented the 24/7 opening at Grantham; as the Trust needed three teams to operate in rotas.  The Committee was advised that work was ongoing with a number of other Trusts regarding the staffing of A & E Departments;

·         One member felt that the using the skills of local GPs would help alleviate some of the pressure at Grantham Hospital.  Confirmation was given that an 'Out of Hours Service' was provided on site by nurses and that signage on site pointed patients in that direction.  It was again confirmed that it had been a decision based on the safety of patients that prevented the opening of Grantham A & E 24/7, as there was insufficient staff as defined by the threshold figures to adequately provide a service.  It was noted that Grantham A & E was less attractive, probably because Doctors generally work in larger teams which enables them to develop specialist skills; 

·         It was noted further that the changes to the HMRC IR35 taxation system implemented from April 2017, had required public sector employers to deduct tax and national insurance contributions from contractors' pay at source, rather than allowing them to defer and claim expenses; this had also had a profound effect on many NHS organisations that employ locum medical staff; and

·         Reference was also made to the success of the Heart Centre, at Lincoln County Hospital.  The Committee noted that this was an example of an excellent service in Lincolnshire, and one that the Trust wanted to replicate, ensuring that the patient received care and treatment at the right place.


It was Proposed and Seconded:-


That recommendation 2 should be amended to reflect the views of the Committee with regard to the addition of the words 'meaningful consultation' and that issues raised should be made to the 'appropriate sections of the NHS'




1.    That the determination of the Secretary of State for Health on the referral of the overnight closure of Accident and Emergency Department at Grantham A & E, and the content of the advice from the Independent Reconfiguration Panel be noted.


2.    That pursuant to the advice of the Independent Reconfiguration Panel, the Committee put on record its position that full, meaningful and transparent public consultation be undertaken on the future of A & E services across Lincolnshire by all appropriate sections of the NHS, to address the issues raised in the report of the Independent Reconfiguration Panel.


3.    That the latest information from the United Lincolnshire Hospitals NHS Trust, regarding their staffing levels for emergency care be noted.


Note: Councillors M A Whittington and R H Woolley wished it to be recorded that they did not support the resolution in 1 above.

Supporting documents:



Original Text: