shaping a healthier future · 2016. 1. 29. · • consolidating these staff at fewer sites will...

Paper: # to be added by each CCG

Date Wednesday, 09 September

2015

Presenter Clare Parker, Chief Officer CWHHE CCGs

Author Oliver Excell (benefits realisation report); NHS England (Independent review report)

Responsible Director

Matt Hannant, Acting Director of Strategy & Transformation

Clinical Lead Mark Spencer / Tim Spicer, Medical Directors SAHF

Confidential Yes No ☐ Items are only confidential if it is in the public interest for them to be so

The Choose an item. is asked to:

NOTE the outputs of the two reports and DISCUSS any conclusions which should be recorded.

Summary of purpose and scope of report

In February 2013, the NWL Joint Committee of Primary Care Trusts agreed to the recommendations made in the Shaping a Healthier Future (SaHF) Decision Making Business Case to reorganise the way in which hospital care is delivered in North West London. These recommendations included the closures of the Hammersmith Hospital Emergency Department and the Central Middlesex Hospital A&E department. The long term aspiration of implementing these recommendations is to raise quality and outcomes for patients in NW London within an environment of provider sustainability.

Following a review of the decision by the Independent Reconfiguration Panel, the Secretary of State for Health reported to Parliament in October 2013 with his decision on the future of the reconfiguration. In line with the recommendations of the IRP report, the Secretary of State told the House of Commons that the programme should continue to implement the changes as planned. In addition to this, it was also decided that due to the viability of keeping the units safely open, the ED at Hammersmith Hospital and A&E and Central Middlesex Hospital should be closed “as soon as is practicable”. Following this statement, a new short term goal was established and planning began immediately to close these units following the winter of 2013/14.

On 10 September 2014, the two units closed in line with the plans which had been agreed

Title of paper Reports examining outcomes arising from closures of Hammersmith Hospital ED and Central Middlesex Hospital A&E


with local CCGs and providers. The closures occurred in a safe and controlled manner, with all stakeholders appropriately involved such as the London Ambulance Service, which enacted new protocols to redirect activity appropriately.

To this effect, the immediate short term goal, which was to safely implement the direction of the Secretary of State to close the two units was achieved successfully.

SAHF set out some specific outcome improvements which are expected to be realised as a result of all of the changes to the urgent care system in North West London. These are in the four areas of clinical quality, patient experience, system wide access to urgent care and staff. A review was undertaken approximately 6 months after the changes to understand whether the expected benefits had been realised by enacting the closures of the two services. This report is attached to this summary document and the conclusions are set out below. It should be noted that the original timescale for the publication of this benefits realisation report was Spring 2015, however, it was not felt to be appropriate to finalise this document until the independent report referenced below was completed.

The benefits realisation report concludes that:

The changes to A&E were delivered safely. Despite the unprecedented pressures on A&E nationwide, NWL was able to implement the changes without increasing the frequency of incidents or emergency admissions.

The changes have allowed A&Es to increase staffing and levels of cover. Consolidation at fewer sites has enabled Trusts to move towards LQS standards of consultant cover, improving care for patients and creating a genuinely 7 day service.

Staff have been upskilled. Comprehensive training has been implemented for UCC and A&E staff. Trainees that were transferred as a result of the A&E closures are now exposed to a wider variety of complex cases.

The changes are part of an ambitious plan to improve care, system-wide. Access to General Practice has been expanded significantly. 24/7 access to enhanced UCC services is now the norm.

We are one year in to a five year programme. We expect the full benefits of the changes to be realised in full over the next 3-5 years as delivery of the Out of Hospital strategy is completed. Prior to the closure, an ‘Operations Executive’ was formed comprising of senior managers from the affected and surrounding Trusts, working in conjunction with CCG leadership. This group continued to meet following the closure to monitor the quality, safety and waiting time performance of all Trusts in North West London. As this group continued to meet and monitor metrics, it became clear that waiting time performance (most notably the 4 hour waiting time target at Northwick Park Hospital) had deteriorated to below an acceptable level. As a result of this, in November 2014, an independent review was commissioned by NHS England into the causes of this performance reduction.


NHS England has now released their report into the changes based on the independent review and it is also attached. This report examines all factors which may have contributed to the decline in performance, including the possibility that the A&E closures in September 2014 had been contributory. The report makes a number of important conclusions and members should read the full detail in order to gain a greater understanding of the dynamics leading to the underperformance at Northwick Park Hospital. Ultimately however, the report concludes that the deterioration in performance was not caused by the closures of the A&E units in NW London. The winter of 2014/15 was particularly challenging for the whole of the national hospital delivery network and Northwick Park was symptomatic of this wider difficulty.

Quality & Safety/ Patient Engagement/ Impact on patient services:

The benefits realisation paper sets out the early indications of improvements in service quality for patients.

Finance, resources and QIPP N/A

Equality / Human Rights / Privacy impact analysis

Equality impact assessments were undertaken before the changes occurred

Risk Mitigating actions

Supporting documents Two supporting documents are attached:

• A&E reconfiguration benefits realisation • A&E Review Report

Governance and reporting (list committees, groups, other bodies in your CCG or other CCGs that have discussed the paper)

Committee name Date discussed Outcome

SAHF Implementation Programme Board (benefits

March 2015 Noted


realisation report)

1

A&E reconfiguration benefits

realisation

July 2015

Governing Body

2

• Objectives and timescales

• Clinical quality

• Patient experience

• System-wide access to urgent care

• Staff

• Conclusion

3

The DMBC set clear benefits for A&E reconfiguration,

focusing on clinical quality and patient experience

• A minimum of 16hrs per day emergency medicine consultant

presence in the ED.

• Reduced admission and re-admission rates

• Reduced number of serious incidents

• Improved training for junior staff

• Greater exposure to complex cases for junior staff

• Improved staff morale

• 24/7 access to improved UCC services

• Improved evening and weekend access to General Practice

• GP appointment within 24hrs

• Reduced A&E attendance/ re-attendance

• Improved patient experience of ED care.

• Improved compliance with 4hr target.

Clinical quality

Staff

System-wide access

to urgent care

Patient experience

4

Good progress has been made, however, the changes

are the first step in a more ambitious improvement plan

Benefits realisation for A&E configuration operates on three distinct

timescales:

1. Immediate: Implementation of the changes is achieved safely, with no negative

impact on the quality of care received by A&E patients. This has been

achieved successfully.

2. Short-term: Rapidly achieved improvements to the quality of A&E provision

brought about by consolidation at fewer sites (e.g. increases in the level of

consultant cover reducing the number of incidents and emergency admissions).

We are on-track to deliver these improvements in-year.

3. Long-term: A&E reconfiguration as an enabler for long-term system

improvement (e.g. improved access to primary care and community-based

integrated care for patients with LTCs). We are only one year into this

programme and have already delivered significant improvements to out of

hospital care

5

Trusts identified significant safety risks at the

Hammersmith and Central Middlesex Hospital A&Es

London North West Hospitals Trust

• Central Middlesex Hospital running at a very high vacancy rate (60% vacancy rate for

nursing and medical staff rising to 85% at weekends)

• High attrition rate of medical trainees and high rate of locum usage at Central Middlesex

Hospital, resulting in a lack of continuity of care

• High rate of locum usage at Northwick Park Hospital (43%)

Imperial College NHS Healthcare Trust

• Hammersmith EU was not staffed by A&E consultants – the doctors in charge of the front

door were acute physicians

• High rate of locum cover (up to 60% of rota)

• Increasing difficulty in covering the out of hours shifts with appropriate locums (with acute

medicine SpR having to cover some of overnight shifts)

• Increased pressure following overnight closure of Central Middlesex Hospital A&E

overnight

Consequently it was agreed that the clinical risk would be reduced by redeploying permanent

staff to wider Trust establishments

6





• Staff

• Conclusion

7

The number of A&E clinical staff has increased across

the sector and training has improved

• As a result of reconfiguration, the number of A&E clinical staff has increased

across the sector.

• Consolidating these staff at fewer sites will enable the sector to improve

levels of consultant cover to comply with LQS standards. This will increase

the quality of care received by patients.

• In addition to increasing the number of staff, existing staff (including UCC

staff) have also been upskilled as a result of the changes:

− Comprehensive local inductions and training needs assessments.

− Greater exposure to complex cases for trainees (as a result of service

consolidation)

− Training for nursing staff taking on new roles

8

The number of A&E clinical staff has increased across

the sector and training has improved

Case study: Imperial

+10

+6 14 ED consultants at St. Mary’s

compared with 8 in July 2014

Additional 6 WTE nurses at St.

Mary’s and 4 WTE nurses at CXH

since September 2014

Additional consultants at St. Mary’s provides

cover until 00.00 on 4 days per week (and

dedicated cover in paeds ED until 20.00 on 4

days per week)

Additional CT3 trust doctor attached to acute

medical team on both SMH and CXH sites,

and Additional GP overnight in UCC at SMH

Case study: Northwick Park Hospital A&E

+22

+5

+15

13.5 ED consultants compared with 8.15

in July 2014

116 ED nurses compared with 94 in

July 2014

40 ED junior and middle grade doctors

compared with 25 in July 2014

Weekdays: 3 ED consultants 8am-10pm; 1

ED consultant 10pm – 12pm

Weekends: Consultant cover 8am-12pm

(compared with 9am-5pm cover in July)

Northwick Park is now delivering the minimum

of 16 hrs of A&E consultant cover, 7 days a

week

St, Mary’s is now delivering the minimum of

16 hrs of A&E consultant cover, 7 days a

week

9

A&E closures have not interrupted NWL’s steady

reduction in A&E incidents

Graph showing reduction in A&E incidents across NWL

0

10

20

30

40

50

60

70

80

90

27/06/14 27/07/14 27/08/14 27/09/14 27/10/14 27/11/14 27/12/14 27/01/15

A&E closure 10th Sep

• A&E incidents are

decreasing steadily across

NWL.

• The A&E closures have not

interrupted this pattern –

A&E incidents continue to

decline gradually.

• The consolidation of activity

at fewer sites will provide the

sector with a platform to

improve performance further.

In line with LQS guidance,

higher levels of consultant

cover at fewer sites will drive

continued reduction in the

number of incidents.

An ‘incident’ defined by the NPSA as ‘any unintended or

unexpected incident which could have or did lead to harm

for one or more patients receiving NHS care’

10

Since August 2014 emergency admissions have fallen

relative to equivalent months from the last 3 years

• Since August 2014,

emergency admissions have

fallen relative to equivalent

months for the last 3 years –

this pattern has not been

disrupted by the A&E

closures.

• The consolidation of activity

at fewer sites will provide the

sector with a platform to

improve performance further.

In line with LQS guidance,

higher levels of consultant

cover at fewer sites will drive

continued reduction in the

number of emergency

admissions.

Graph to show monthly emergency admissions (2011/12 – present)

11000

11500

12000

12500

13000

13500

14000

2011/12 2012/13 2013/14 2014/15

11





• Staff

• Conclusion

12

NWL A&Es are successfully treating more patients within 4 hours than ever

before and despite a challenging winter NWL A&E performance remained

above both the London and national average

• Performance nationally dipped over winter but across Q3 the North West London sector was the

highest performing in London – at 92.87% - for all type A&E performance and was above both

the London and the national average performance for the quarter.

Total patients seen with 4 hours in the North West London area

Q4 2009/10 (standard was 98%) Q3 2013/14 Q3 2014/15

253,361 297,375 304,319

Sector / Region Q3 2014/15 All type

A&E performance

North West London

area

92.87%

North East London

area

92.01%

South London area 92.27%

London 92.34%

England 92.56%

Pe

rce

nta

ge

of

NW

L A

&E

att

en

dan

ces s

een

wit

hin

4h

rs

NWL A&E (all types) performance against 4hr target (Jun 14 – Feb 15)

84.0%

86.0%

88.0%

90.0%

92.0%

94.0%

96.0%

98.0%A&E closure 10th Sep

90% target

A&E performance recovered

and in Q3 14/15

outperformed rest of London

and national average

13

Friends & Family Test data show high levels of

satisfaction with A&Es in NWL

• Despite the unprecedented

pressure on A&E services

in November and

December 2014, patient

satisfaction remains high

(and in some cases

significantly higher than the

national average).

• Northwick Park Hospital

A&E experienced well

documented challenges

during winter, however, the

opening of the new A&E

department has ameliorated

these and we fully expect to

see a significant

improvement in FFT scores

when the January 2015

results are released.

92% 89% 93% 93%

59%

84%

97%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

CharingCross

Hospital

Chelwest EalingHospital

HillingdonHospital

NorthwickPark

Hospital

St. Mary'sHospital

WMUH

England average 86%

Graph showing proportion of patients who would

recommend A&E service to friends and family (Dec 2014)

14





• Staff

• Conclusion

15

Significant improvements have been made to NWL’s

Urgent Care Centres. All nine now operate 24/7.

Map showing UCCs in NWL • SaHF developed a new ‘enhanced’

UCC service specification, enabling

UCCs to manage minor injuries

(including fractures) in addition to

minor illness. This specification is

being replicated nationwide.

• All UCCs in North West London are

now operating 24/7

• The new specification has been rolled

out across 5 UCCs in NWL, and will

be extended to cover all 9 in the near

future.

• Expanded UCC provision is enabling

patients to access urgent primary care

as near to their home as possible. The

services are proving popular with

patients and are a key element of our

approach for reducing pressure on

A&E

• Almost all (97%+) UCC patients are

seen within the 4 hour waiting time

target.

Northwick Park UCC

CMH UCC

St. Mary’s UCC

Charing Cross UCC

Ealing UCC

Hillingdon UCC

Hammersmith UCC

Chelwest UCC

WMUH UCC

16

Successful UCC re-specification has allowed NWL to

reduce pressure on A&E despite increasing demand

Graph showing change in the average daily

attendances at A&E (type I) and UCC (type III)

across NWL between 2013 and 2014 (for period

between 11th Sep and 16th Nov)

-101

178

76

-150

-100

-50

0

50

100

150

200

A&E UCC A&E + UCC

• We compared average daily UCC/A&E attendance

across NWL for a two month period after the closures

(11th Sep – 16th Nov 2014), with the same period in

2013.

• We found that:

1 Total UCC/A&E demand has increased across

the system by 76 attendances per day.

2 Despite increased demand , we have

successfully reduced pressure on A&E services.

A&E activity has fallen by 101 attendances per

day.

3 This has been achieved by a significant

expansion of UCC provision (an additional 178

attendances per day), providing patients with

improved access to urgent primary care and

diverting inappropriate activity away from A&E.

The re-specification of Hillingdon UCC in

particular has supported this shift (90 additional

attendances per day).

Ch

an

ge

in

dail

y a

tte

nd

an

ce

17

Urgent access to primary care has increased across

NWL – 1 million more residents now benefit

¹Often as part of a network

• A key element of SaHF has always

been to move care into an out of

hospital setting, enabling patients to

receive treatment as close to their

homes as possible.

• A&E consolidation is one element of

a system-wide approach to

expanding access to care.

• We know that many people use A&E

as an alternative to primary care, so

improving urgent access to General

Practice is fundamental to our

strategy.

500,000 500,000

1,800,000

1,500,000

-

200,000

400,000

600,000

800,000

1,000,000

1,200,000

1,400,000

1,600,000

1,800,000

2,000,000

Access to evening appts. Access to weekend appts.

Change in access to General Practice

Jun-14 Jan-15

No

. N

WL

re

sid

en

ts

• In parallel with A&E reconfiguration, NWL has made the following improvements in GP access:

− 1.5m people have access to GP appointments on the weekend.

− 1.8m people have access to GP appointments in the evening.

− 80% of GP practices offer telephone triage and consultations

− 84% of GP practices can ‘almost always’ provide an urgent appointment within 4hrs and a routine

appointment within 48hrs.

18





• Staff

• Conclusion

19

The changes have improved the quality of experience

and training available to staff

Staff skills and training

• Comprehensive local inductions and training needs assessments were conducted as

part of the A&E reconfiguration. Extensive training programmes for both transferring

and in-situ staff were then implemented.

• The consolidation of A&E services has increased the breadth of experience available

to trainees. Fewer, larger units provide trainees with greater exposure to complex

cases.

• All changes to training and education are being closely monitored and evaluated by

HENWL.

20

UCC staff now possess a more comprehensive set of skills and

capabilities than they did prior to the changes • The enhanced UCC specification defines a more demanding set of minimum competences for UCC clinicians.

• HENWL provided funding (£500 / head) to support the additional training requirements to meet the enhanced UCC

specification at Hammersmith and Central Middlesex

• Two training days were delivered by Imperial for the Hammersmith UCC GP staff to provide the mandatory training

for these staff, covering:

• General overview and sick person

• Chest pain and palpitations

• Shortness of breath

• Abdominal pain – when to get imaging

• Interpretation of ECG

• Interpretation of CXR

• Recognition of the sick child – what you can do in an emergency.

• Basic Life Support training was also provided to all of the Hammersmith Urgent Care Centre reception staff

• At CMH UCC additional training was rolled out to all full time GPs and nurses in*:

• Prompt – assisted deliveries for pregnancy

• ECG interpretation

• Resuscitation and emergency simulation

• Life Support training

• All clinicians are now ILS trained and a high proportion are ALS and APLS trained

• All CMH UCC administration also received basic life support training

*Note: A significant proportion of the self employed GPs at CMH UCC also enrolled on these additional training courses

21





• Staff

• Conclusion

22

A&E reconfiguration has been implemented safely and is

on-track to deliver long-term benefits for NWL patients

• The changes to A&E were delivered safely. Despite the unprecedented

pressures on A&E nationwide, NWL was able to implement the changes

without increasing the frequency of incidents or emergency admissions.

• The changes have allowed A&Es to increase staffing and levels of

cover. Consolidation at fewer sites has enabled Trusts to move towards

LQS standards of consultant cover, improving care for patients and creating

a genuinely 7 day service.

• Staff have been upskilled. Comprehensive training has been implemented

for UCC and A&E staff. Trainees that were transferred as a result of the A&E

closures are now exposed to a wider variety of complex cases.

• The changes are part of an ambitious plan to improve care, system-

wide. Access to General Practice has been expanded significantly. 24/7

access to enhanced UCC services is now the norm.

• We are one year in to a five year programme. We expect the full benefits

of the changes to be realised in full over the next 3-5 years as delivery of

the Out of Hospital strategy is completed.

Review of the Implementation of North West London A&E Changes 1. Introduction This paper is NHS England London Region’s report on the independent review of the impact of the closure of Central Middlesex and Hammersmith Hospitals Accident and Emergency (A&E) departments on performance against the A&E targets. It covers the background to the changes, key aspects of the implementation, the independent review and key conclusions from it. 2. Background In February 2013, the Joint Committee of North West London PCTs (JCPCT) decided on a reconfiguration of acute services in NW London following public consultation. In making this decision they received written support for the decision from the emerging CCGs in NW London. The decision was referred to the Secretary of State who asked the Independent Reconfiguration Panel (IRP) to undertake a review in line with standard practice. Their report, and the Secretary of State’s decisions based on it, was published in October 2013. One of the IRP’s recommendations, based on the clinical and other evidence they received was: “As part of a staged approach for implementing Shaping a Healthier Future, the proposals for A&E services at Hammersmith and Central Middlesex hospitals should proceed as soon as practicable”1 In support of this recommendation, the IRP report states: “5.5.12 With regard to the existing A&E at Hammersmith Hospital, the Panel found that, while residents considered it to be a valuable service, the range of conditions able to be treated is constrained by the absence of relevant back up services such as emergency surgery. Both the commissioners and provider of this service agree that better care could be provided by concentrating A&E resources at St Mary’s Hospital linked to a 24-hour urgent care centre at Hammersmith Hospital. 5.5.13 The A&E service at Central Middlesex Hospital is also limited in the range of conditions able to be treated. It is currently open for 12 hours a day. Whilst this service provides some capacity to the A&E system in North West London, the panel accepts that a more effective option is to concentrate A&E resources at Northwick Park linked to a 24-hour urgent care at Central Middlesex Hospital” Subsequently, Imperial Healthcare Trust (which is responsible for the Hammersmith Hospital) and North West London Hospital Trust (Central Middlesex) again raised concerns with local CCGs regarding their ability to run safe Accident and Emergency services on these sites in the light of on-going staffing challenges. Central Middlesex’s A&E had a 60% vacancy rate for nursing and medical staff rising to 85% at weekends which required extensive use of locums and agency staff resulting in poor continuity of care. Northwick Park also had a 43% locum rate which merging the departments’ staffing was expected to improve. The College of Emergency Medicine removed accreditation of Hammersmith A&E over ten years ago and since then the A&E service had been provided by consultant physicians. Hammersmith Hospital also had a locum rate of up to 60% with increasing difficulty in covering out of hours shifts leading to some overnight shifts being staffed by general medicine specialist registrars (SpR).

1 ‘Advice on Shaping a Healthier Future Proposals for Changes to NHS Services in North West London’, IRP 13 September 2013.

1 NHS England London Region, July 2015

3. Preparations for Closures

Trusts worked with the ‘Shaping a Healthier Future’ (SaHF) programme to agree when would be ‘as soon as practicable’. They recommended the two units should close simultaneously to simplify communication with the public and to avoid some patient flows displacing to a unit scheduled for closure. It was agreed to close both units on 10 September 2014 to allow time for all the necessary preparation and for new patient pathways to ‘bed-in’ before Winter. The overall design was to:

• Close Emergency capacity at the two sites and reprovide that capacity at receiving sites (mainly Northwick Park and St Mary’s Hospitals).

• Improve the quality of care at receiving sites by redeploying clinical staff to them from the closing A&Es

• Increase urgent care capacity by providing 24/7 urgent care centres (UCCs) at both sites operating to an improved specification.

It should be noted the changes were not predicated on delivering more care in primary and community care settings which is a longer term aim of the SaHF programme. The intention was reprovide at least the same level of A&E capacity at the receiving sites as previously available at the closing sites as well as increased urgent care capacity at the closing sites. The planning for the operational delivery of the programme was undertaken by:

• Project teams for Hammersmith and St Mary’s Hospitals and Central Middlesex and Northwick Park Hospitals with clinical leadership/ membership reporting to their Trust Boards and the SaHF Implementation Board

• Oversight by Trust Boards who received regular papers • The Shaping a Healthier Future Implementation Board which was responsible for

assurance and coordination • An Operations Executive comprising Operational managers from all hospital Trust

and London Ambulance. Internal assurance was undertaken by Trust Boards, the SaHF Implementation Board, NHS England (NHSE) with the Trust Development Authority (TDA) and relevant Clinical Commissioning Groups (CCG) Governing Bodies. External assurance was undertaken by NHS England, the Trust Development Authority and Monitor (‘the Tri-Partite’).

4. Safety Evidence suggests the A&E changes were implemented safely and led to improved staffing. A&E incidents2 had been reducing across NW London and this trend was not affected by the A&E changes.

2 An ‘incident’ defined by the National Patient Safety Agency (NPSA) as ‘any unintended or unexpected incident which could or did lead to harm for one or more patients….’


The potential impact of the changes on ambulance travel times from scene of incident to A&E was highlighted through engagement prior to the changes. Data from London Ambulance Service (LAS)3 shows that the increase in travel times to A&E has been smaller than expected.

Difference average scene to hospital (mm:ss)

A&E Site Northwick Park Hospital +00:47 Hillingdon Hospital +00:22 Ealing Hospital +01:04 West Middlesex Hospital +00:27 St Mary’s Hospital +01:25 Chelsea & Westminster +00:25 Charing Cross Hospital +01:03

5. Independent Review of A&E Performance

Introduction NHS England commissioned an independent review of A&E performance on behalf of the Tripartite. The reviewers were asked to:

• Review A&E performance at all North West London urgent and emergency care sites

3 LAS evidence to NW London JHOSC, 3 March 2015

0102030405060708090

27/06/14 27/07/14 27/08/14 27/09/14 27/10/14 27/11/14 27/12/14 27/01/15

Graph showing reduction in A&E incidents across NWL A&E closure 10

th Sep


• Investigate links between performance and the A&E changes. We agreed with the reviewers that their main analysis should compare October 2015 (the first whole month post-implementation) with October 2014.

• Make recommendations regarding any lessons that should be learnt regarding the planning for and implementation of, the changes.

A&E Performance In order to prepare for the transition, the SaHF programme undertook detailed modelling to predict the redistribution of patients attending and requiring admission by site. The diagram below shows this modelling at a high level to show the general expected patient flows. Modelled Anticipated Patient Activity Flows

The review found the actual redistribution of patient activity from Central Middlesex and Hammersmith Hospitals to receiving sites was in line with, or lower than, the SaHF modelling predicted. The October 2014 v 2015 comparison showed overall emergency admissions in NW London were lower in 2015. However, the review found significant variances in demand unrelated to the closures which led to local performance issues. Hillingdon and Harrow CCGs saw month versus month increases of 7% and 6% respectively which impacted their local A&Es of Hillingdon and Northwick Park. The review did not find evidence of ‘overflow’ from the new receiving sites to other NW London sites. For example, in view of travel times, SaHF predicted no impact on Hillingdon and the review found this was true in October. Hillingdon Hospital did however experience an increase of 8 admissions per day due to the local increase in demand from Hillingdon CCG (referred to above), with consequent impact on its performance.

Northwick Park

Hillingdon

WMUH

St Mary’s

C&W

Ealing Charing Cross

CMH

Royal Free

+ A&E Attendances /day

+ NEL Admissions/

day

1 0


+ NEL Admissions/

day

36 18


+ NEL Admissions/

day

3 1


+ NEL Admissions/

day

10 3


+ NEL Admissions/

day

11 3


+ NEL Admissions/

day

24 8


+ NEL Admissions/

day

1 0.5


+ NEL Admissions/

day

1 0

Hammersmith


A&E performance is measured against the 4 hour A&E target, which is that 95% of patients should be seen, treated, admitted or discharged in under four hours. There was deterioration in A&E performance in NW London A&E sites during and after the A&E transition. However, this deterioration was in line with deterioration across London and England and the review found it was not related to the A&E changes. For example, for the quarter October – December 2014, as a whole, NW London’s ‘all type’ A&E performance fell to 92.9% (compared with 96.1% the previous quarter). However, the all London performance fell to 92.4% and NW London had the best performance of the three London sectors. In the quarter January – March 2015, NW London achieved 93.6% (London 92.6%). Currently NW London is achieving 94.7% (London 94.2%). As referred to above, the SaHF programme modelled predicted attendances and admissions at receiving A&Es and hospitals and actual activity aligned well with this modelling. Individual Trusts were responsible for modelling the impact of this activity on their facilities and the provision of additional capacity, including A&E, beds and staff. The SaHF and Trust modelling was subject to assurance by NHS NW London Clinical and Implementation Boards and the regional Tripartite. In general, Trust modelling also proved accurate, however, the independent investigation found an increase in the acuity of patients being treated in October 2014 (compared with 2013). In summary, whilst the total numbers of patients were accurately predicted, they were at the higher end of the acuity spectrum than normal. As an example of this increased acuity, the review found whilst ambulance conveyance to A&Es were actually 11% lower in October ’14 compared with October ’15, the absolute number of Category A arrivals (the most acute) rose by 3%. In October 2013, 217 of 472 patients were Category A. In October 2014 it was 225 of 418. The review found a rise in acuity in ambulances conveyances across London as a whole but the NW London rise was greater than other areas. The review confirmed the underlying cause for this increase in acuity could not have been linked to the A&E changes. There was a national increase in demand and acuity over the Winter of 2014/15. It is known that the 14/15 flu vaccination was ineffective against the main H3 flu strain (which is known to particularly affect the elderly) this Winter. Nationally, Public Health England observed excess deaths from respiratory illness, mainly flu, amongst the elderly from late September 2014 into January 20154 This rise in acuity adversely impacted receiving hospitals’ patient flow compared with their models. The biggest impact was at Northwick Park. SaHF predicted that Northwick Park Hospital would receive an additional 18 patients per day and the Trust opened an additional 29 beds to accommodate them. Of the 18, the Trust expected 12 patients would require admission and the remainder could be treated through an ambulatory pathway and not require hospital beds. In practice, 16 additional patients per day required admission. Similarly, the Trust expected the patients admitted to have a length of stay of 3.5 days whereas their actual length of stay was 4.5 days. The review shows the combination of 4 additional patients per day with a longer length of stay meant the hospital had an effective bed deficit of over 20 beds and this deficit drove the deterioration in the hospital’s A&E performance. Subsequently further beds were commissioned and A&E performance improved. Lessons to be learned The independent review concluded that the assurance processes used in preparation for the change were extensive. However, the assurance process should have undertaken further

4 Public Health England, Weekly All-cause Mortality Surveillance, 29 January 2015


testing of hospitals’ key assumptions and further sensitivity testing. For future similar changes, the review recommends:

• Clear identification of key assumptions on which planning is based. • Understanding the rationale for assumptions and the evidence upon which they’re

based • Ensure sensitivity testing encompass the most significant potential variables.


shaping a healthier future · 2016. 1. 29. · • consolidating these staff at fewer sites will...

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