Yesterday, Mike Gapes MP participated in a Westminster Hall debate on the future of Barking, Havering and Redbridge University Hospitals NHS Trust.
In his opening speech, Mike said:
I begin by declaring an interest: I was a patient at Queen’s hospital in January. My operation was cancelled at two hours’ notice, but despite that hiccup I was given excellent treatment a couple of weeks later. I want to place on the record the fact that despite being in a very busy department, the staff were working very well and had excellent morale, as far as I could see during my groggy recovery from my operation.
The Barking, Havering and Redbridge University Hospitals NHS Trust was established in the 1990s. It brings together two acute general hospitals—King George hospital in Ilford in my constituency and Queen’s hospital in Romford, which was a new-build private finance initiative hospital to replace the old church hospital.
Since 2006, there have been many pressures for reorganisation of services in north-east London. There was a misnamed project called “Fit for the Future”, which was scrapped because it was clinically unsound. Since then, there have been proposals that would have meant downgrading services at some hospitals, particularly King George hospital. To cut a long story short, an independent reconfiguration panel looked at the proposals, and eventually, in 2011, the then Secretary of State for Health, Andrew Lansley, gave the go-ahead to close the maternity and accident and emergency services at King George hospital in around two years. The maternity services were reconfigured in early 2013, but A&E is still at King George hospital.
The trust is very big. There are 750,000 people in its catchment and it covers three London boroughs—Barking and Dagenham, Redbridge, and Havering. Havering has an elderly population overall, but Barking and Dagenham and Redbridge have some very young people. There is a churning population, with lots of migrants, from both elsewhere in the UKand many other parts of the world. GP services and primary care services have been poor and inadequate for many years. There have always been pressures on the hospitals and trusts in north-east London. Those pressures have led to accumulated deficits and concerns about the quality of service.
In October 2013, the Care Quality Commission carried out an inspection of the services at the Barking, Havering and Redbridge trust. It concluded that the trust should be put into special measures. The press release put out on December 18 said:
“The NHS Trust Development Authority…today confirmed that Barking, Havering and Redbridge…will be placed into special measures. The move follows the CQC Chief Inspector of Hospital’s report…which concludes that while there have been signs of sustained improvements in some areas, the leadership of the Trust needs support to tackle the scale of the problems it faces. While aware of many of the issues raised by CQC around patient safety and patient care, attempts to address these issues have had insufficient impact.”
As a result, the trust was put into special measures and all the management were got rid of. It took a while to fill the various posts, but an interim chief executive was
brought in and other posts were changed. I have been impressed with the chief executive, Matthew Hopkins. He and the team around him are doing their best to improve services in the area. However, fundamental, difficult problems remain.
The CQC’s 2013 report, which led to the involvement of the NHS Trust Development Authority, highlighted a number of areas of concern, and follow-up work was carried out. One underlying issue was the financial crisis, which remains at the trust. A new finance director, Jeff Buggle, was appointed in July last year, although he did not take up his job until December. The press release at the time he was appointed said that the trust had a £38 million deficit, with expenditure of somewhere around £400 million or more in 2013-14. I understand that the target for the deficit this year was £29 million, but that has not been met; the deficit remains at about the level it was a year ago. That is not surprising; the Health Service Journal from June 26 this year has an interesting statement from Richard Douglas, the former director general for finance at the Department of Health. He said that trusts placed in special measures “tend to exit the regime with a financial position that had deteriorated”.
The reason is that there is so much pressure to improve services that the expenditure must continue.
It is a bit like the situation in Greece: we have an underlying deficit, a temporary troika, or body, comes in to sort out the problems and the trust is put into special measures. Fortunately, we do not have a far-left, far-right coalition running the hospitals. Nevertheless, we face fundamental difficulties.
The special measures, which were called for, have led to a number of changes. I wish to draw attention to the further inspection that the CQC carried out in March, the results of which were published only at the beginning of July. To the disappointment of the new leadership of the trust, the CQC says that BHRT must remain, for the next few months at least, in special measures. The CQC’s latest report says that although improvements have been made in a number of services, many are still rated as requiring improvement. Professor Sir Mike Richards concluded that significant improvement was still required, and therefore there will be a further inspection before the end of the year to see whether other changes have been introduced since that assessment was made in March.
Clearly I do not have time, even in an hour-long debate, to go through the voluminous reports—the general one and the one on each of the hospitals in the trust—but I will refer to some of the main points. I hope the Under-Secretary of State for Health can reassure me on some issues in his response.
First, I want to make it clear that anything I say here is not a criticism of the staff in my local hospitals. They face enormous pressures; we have a trust that faces huge demand and there are huge pressures on it. I will just give some figures. There are just over 1,000 beds in the two hospitals, of which 80 are maternity beds, 32 are critical care beds, and 972 are general and acute beds. There are 73,000 in-patient admissions, 592,000 out-patient attendances and 245,000 emergency department attendances each year. That figure of 245,000 is divided into 97,000 attendances at King George hospital in Ilford, which Andrew Lansley said in 2011 should be closed within about two years, with the rest—nearly 150,000 attendances —at Queen’s hospital in Romford.
Average bed occupancy in the hospitals is consistently around 93%, 94% or 95%. There is almost no flexibility, and my own experience in January of having an operation cancelled at short notice is sadly repeated from time to time. We had a mild winter and yet operations were being cancelled in January. The same pressures will come each year in this area in outer north-east London, which has a young population and rapid population growth.
I will refer to some of the issues affecting the hospitals. I begin by quoting Mike Richards again:
“Despite considerable attention the trust is failing to meet waiting time targets in the emergency department. Outpatients and diagnostics can’t cope with demand and the children’s services do not meet local need.
I am particularly concerned at the large backlog of investigations into serious incidents, which suggests that safety has not been given the priority it requires and lessons are not being learnt as they should.
However, the new executive team has made significant improvement ensuring the overall culture of the trust was more open and transparent making it a much more positive place to work.”
The point I am making is that this trust needs support, and it needs that support to continue for a period of time.
The CQC report asked whether services at the trust were safe, effective and caring. The rating for all three was “Requires improvement”. It asked, “Are services at this trust responsive?” The rating was “Inadequate”, which is the red one on the traffic lights. It asked whether services were well led; the rating was “Requires improvement”. That is the overall rating for the trust—“Requires improvement”—and there are particular concerns about urgent and emergency services.
The CQC report covers a range of different services at the two hospitals, but the essence of the report is that there are major difficulties, and I will refer to just a few of them. First, the report says that “The service planning for children’s services was not responsive to local needs.”
Secondly, it says that “The trust faces significant capacity pressures which it has tried to address”.
Thirdly, it says that “Across all core services there was limited evidence of learning from complaints and concerns being applied to service improvement. We identified areas where complaints response was slow leading to backlogs, lack of action planning and absence of thematic analysis.”
Fourthly—and this is very significant—it says, under the heading “Governance, risk management and quality measurement”, that
“Amidst many improvements within the trust since our last inspection, governance, risk management and quality measurement is an area of significant concern as little improvement has been made…Previous cost reduction plans had significantly reduced the infrastructure to support governance and safety.”
This is a trust with a deficit of about £37 million or £38 million, and it has to eliminate that deficit. When it comes out of special measures—as it no doubt will, perhaps in a few months or maybe in a year, depending on what the next inspection says—it will still face these financial pressures. One of the reasons why it has had difficulties is that it has already had to subject itself to those pressures.
The CQC report continues:
“There is a heavy reliance on individuals and the use of short term interim staff.”
Recruitment and retention of staff have been major difficulties, and they have added to the cost pressures.
We face a difficult situation. We have a management—a leadership—that is trying to turn the trust round, and they are doing much better than their predecessors. They face enormous pressures, and those difficulties are perpetuated and even made worse by the cuts in social care at local authorities, the fact that we have inadequate GP services and the fact that many people just present themselves at accident and emergency rather than going to a GP. That is because they have been trying to get an appointment with their GP for two weeks, and, in the case of the Loxford polyclinic in my constituency, they have been phoning for hours but cannot get through because there is a problem with the switchboard. The same problems arise in a more intense way while the trust is dealing with this financial crisis.
What is the way forward? I will speak for just a few more minutes, to allow my colleagues the chance to contribute to the debate. The CQC report carries out a “Friends and Family test”, and I find the results for the trust extremely concerning. In the test, there is an assessment of the different departments. The report says:
“NHS Friends and Family test (July 2014)—average score for urgent and emergency care was 20%, which was worse”—
in fact, considerably worse— “than the national average of 53%.”
The report continued:
“The average Friends and Family score for inpatients was 73, which is the same as the national average…The Friends and Family score for maternity…was 70, which was better than the England average of 62.”
So it is not all bad news.
However, the urgent and emergency care is a significant problem, yet the Government decided in 2011, based on the independent reconfiguration panel and the CQC report, that the A&E department at King George hospital should be closed and all A&E services should be relocated to Queen’s hospital. Queen’s cannot cope as it is. Consistently, the Queen’s A&E has had worse assessments than the King George A&E. Yet the sword of Damocles is still hanging over the A&E at King George, and there is this mass of 245,000 patients who go to the A&E departments at the two hospitals, which they cannot cope with.
Let us suppose that the assessment in December, or whenever it is, leads to the trust coming out of special measures next year. What will that mean? What will the consequence of that be? I will quote the summary of the CQC report on urgent and emergency services. The “Friends and Family test”, which I have just quoted, said those services were
“showing no signs of improvement over the 12 months prior to the inspection. The hospital had not achieved the national four-hour waiting target of 95% of patients seen within this timeframe for more than a year, and usually averaged around 90% of patients seen within this time. Patients often had waits of four hours or more in the department and were waiting for long periods of time to be moved to an appropriate bed once it has been decided they should be admitted.”
This is the key sentence: “There was no clarity about the future of the department and when, or if, it might close in the future.”
This has been hanging over my local hospital since 2006. We have fought vigorous community campaigns and the issue is still hanging over it. There is no clarity. If, because of improved management, the situation improves
later in the year and the trust comes out of special measures, will that mean—I suspect it will—that there will then be moves to close the A&E at King George because the trust is no longer in special measures? There is not the capacity at Queen’s to deal with that. It will take years, considerable cost, and millions of pounds of investment on the Queen’s hospital site before Queen’s hospital is ready to cope with this situation.
Rather than wasting millions of pounds and causing more difficulties for several years, would it not be better if the sword of Damocles was taken away, thereby ending the uncertainty and lack of clarity mentioned in the CQC report? Then we could deal with the problems of recruiting sufficient specialist doctors and having adequate cover at all times, and maybe work out a plan for a relationship between the two acute and emergency departments whereby there would not be a closure, but perhaps a rethink about how services were run.
Clearly, Queen’s cannot cope today. However, it is still the Government’s plan to close King George. I have asked Ministers about this for several years and the answer has never changed. There is still uncertainty. What will the future of King George be? It is time to end the uncertainty, to give a sense of clarity and, as the trust improves, to take away the threat to close the A&E department at King George.
A full transcript of Mike's opening speech and contributions by other Members of Parliament be read here.