West Middlesex Hospital is being less than transparent in its dealings with patients waiting in A&E. Here is an anecdotal report from a clearly anxious man supporting his wife there, as reported in the Community Forum of ChiswickW4.com, dated 9th November.
"I am not sure what West Middlesex is playing at. I had to take my wife there 3 weeks ago at approx 8.30pm on a Saturday night. Reception told us there was a 4 hour wait even though it didn’t look too busy. They asked us if we wanted to wait!! Not sure what they expected us to say....why would we go to A&E if we didn’t think we needed a doctor? The whole time we waited the TV screens reminded us that there was a 4 hour wait. As far as I could see some people who arrived after us who were deemed to be ‘more urgent’ were seen within half an hour to an hour. I didn’t have a problem with that as I fully appreciate some issues are more urgent than others. My wife was seen after about 2 hours and by that time there were only 4 patients waiting. However, the TV screens still ‘warned’ people that the waiting time was 4 hours. As we were leaving the reception was still telling newcomers that the wait would be 4 hours even though she could clearly see there were very few people still waiting. Why would they do that? Is it to try prove a point regarding statistics or......??? I really can’t figure out the motivation in wanting to make poorly people more anxious".
What West Middlesex is not telling this patient is that the management accountants of West Middlesex University Hospital NHS Trust do not really want to offer an A&E service because, above a baseline number of patients, they are "losing money" i.e. not being properly reimbursed by the NHS for treating A&E patients. This is a hidden truth: it is well known in NHS circles, but not known by the general public. Please see the summary of the National Audit Office report of 7th November 2014 below.
The first reason given for this is that "providers and commissioners in financial difficulty have not matched pressures on funding with equivalent reductions in spending". In other words they both overspend because they find it impossible to drive a hard bargain.
The second reason is extremely material to our campaign. "Despite payment for emergency admissions at a 30% marginal rate, demand continues to increase". It continues: "Trusts are paid at a marginal rate of 30% of the full tariff [true cost] for all emergency admissions above a baseline set from the number of admissions in 2008-09. The Department introduced this payment method to discourage unnecessary emergency admissions. We reported in October 2013 that emergency admissions had increased in 62% of trusts since the introduction of the marginal rate for emergency admissions. Case study trusts told us that demand is increasing, and it is not always possible to discharge patients into the community in a timely way. All the acute trusts we spoke to told us that payment for emergency admissions did not meet their costs. In practice, payment at the marginal rate may not give commissioners strong enough incentives to make alternative community care available. Increasing demand for emergency admissions will also reduce the resources commissioners have to invest in alternative primary or community care (paragraph 2.7)
This deliberate underfunding of emergency admissions has not made the emergency admissions "go away"! It has in fact made it MORE difficult to fund alternatives in the community.
Under "Managing Financial Risks", the report notes "NHS trust and foundation trusts under financial stress continue to rely on cash support from the Department [of Health]. In 2013-14 the Department issued £511 million cash support to 21 NHS trusts and 10 foundation trusts in the form of revenue-based public dividend capital (PDC) [long-term finance initially offered to trusts to enable them to buy their assets from the DH]. This is an increase of £248 million compared with 2012-13. The Department provides revenue-based PDC so that organisations in difficulty have the cash they need to pay creditors and staff. Since 2006-07, the Department has issued a total of £1.8 billion revenue-based PDC, of which £160 million has been repaid.
Financial plans submitted by commissioners and providers covering the 2 years 2014-15 and 2015-16 have had to be revised and 2015-16 are not yet finalised.
There remains considerable uncertainty about the impact on 2015-16 plans of initiatives such as the Better Care Fund, which both the Department and NHS England expect to reduce demand for acute hospital services. We will revisit this planning process for commissioners and providers in 2015, when relevant data will be more stable".
The "Independant" ran the headline "NHS facing £700m black hole over failing Better Care Fund" based on this aspect of the NAO report.
"Relationships between local bodies are not mature, and it is not clear where responsibility for strategic change will lie. Commissioners and providers told us the new structure felt fragmented, particularly at regional level. Senior staff we interviewed in NHS trusts and foundation trusts thought no organisation was responsible for taking a strategic view across the whole local health economy, but they were trying to bring about the transformational changes needed".
The lack of planning at regional level has been apparent ever since Strategic Health Authorities were abolished in 2013.
"These trends are not sustainable. An increasing number of providers and commissioners are in financial difficulty".
The NAO suggests solutions including tapering "cash top-ups" to providers in trouble, long-term better planning (including chasing laggards) and stronger direction to be exercised by NHS England.
In terms of Value for Money: "Until the Department explains how it will work with NHS England, NHS TDA [Trust Development Authority] and Monitor [regulates foundation trusts] to address the underlying financial pressures, quickly and without recourse to annual cash support, we cannot be confident that value for money, in terms of financial and service sustainability, will be achieved over the next 5 years".
The Care Quality Commission conducted an inspection of Chelsea and Westminster hospital in July 2014, i.e. before the closures of Central Midd and Hammersmith A&Es. In an inspection generally very positive about C&W, the A&E was considered as "requiring improvement." Report extracts include:-
“There had been an increase in demand for services, and the capacity in some areas of the trust, such as A&E, experienced difficulties in meeting this additional demand. Staff reported that a contributing factor to this increase was due to the local reconfiguration of services across London.”“Medical staffing levels did not meet national recommended standards in A&E.”“Patient care in A&E was good but the service was under increasing pressure and attendances were increasing, which was causing delays in assessment and treatment.”
Specific areas of risk were not managed appropriately: the timings for ambulance handover; triage and assessment of patients in A&E and consultant sign-off when they left the department.”
“Staff in A&E told us that there was low morale.”
The assessments of the needs of service users were not always undertaken in a timely fashion either when arriving by ambulance or attending on foot in the A&E. The lack of space in the A&E department compared to the number of patients admitted meant that patients often received care and treatment in environments that were not suitable and where it was difficult to appropriately monitor their condition Patients in A&E were, at times, being treated in the corridors of the A&E and their privacy and dignity was not maintained
New NHS boss Simon Stevens made headlines today presenting NHS England's latest 5-year plan. The plan is clearly based in part on the experiments on North West Londoners under the banner of "Shaping a Healthier Future". So we've become accustomed to promises of more care in the community, integrated care, acute specialisms - aspirations in themselves as uncontroversial as apple pie.