A & E waiting times week ending 30th November 2014: worst ever!


The tone of this e-mail is a little "tongue-in-cheek" - but the statistics quoted are unfortunately all too true.

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Date: 5 December 2014 at 17:30
Subject: Worst Again
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Dr Spencer,


It is reported that you have gone on the £120,000 junket to America.  I continue to hope not.  Quite what you would have expected to discover there after you spent over £3.5 million on McKinsey's advice for Shaping a 'Healthier' Future it is hard to imagine.  I look forward to a full and costed report of the findings.


Many people feel that your time would have been better spent in dealing with the increasing A&E crisis in NW London.  'Crisis' has ceased to be the appropriate word;  it is a catastrophe.


It now almost goes without saying that in the week ending 30 November London North West Healthcare was the worst Trust in the country for Type-1 waits at 65.7%, over 5 percentage points worse than the next.   And it was the 14th worst for 'All attendances', out of some 280.


And that week the North West London Sector was the worst in the country, if it were taken as an 'Area Team' of its own – which it could easily be, given its size and activity levels.  As you know, there are 25 Teams including London and NW London was 6.9 percentage points lower than the worst of those for Type-1s, at 79.9%.  Against the 95% target for 'All attendances' it was the worst again, managing 91.2% compared with 96.5% for the rest of London.


So, instead of swanning off to the States, all you had to do was to talk to your colleagues in London to find out how to run A&E services.  30% of all London Type-1 waits occurred in the area under your supervision.  So, when you said 'We think there are many other factors going on across London,' you failed to point out that you were attracting more than your fair share of whatever you think these might be.


There again, I am not aware that any other London Sector has decided to axe 2 of its central A&Es, reduce bed capacity (until the recent frantic reversals) and invite ambulance crews to telephone for an appointment to deliver a casualty to a 'Major Hospital'.


Your position is increasingly untenable.


Colin Standfield


Imperial board meeting 26th November 2014 Key Points

Project diamond predicted income at risk, if they don't get both components 


P 8


Bill Shields " He believed the Trust would still receive £7.2M for Project Diamond but not necessarily £10M for market forces which would see the Trust reduce its surplus from £11.2M to £1.2M". 


Jolly to USA (we found at meeting it is organised by McKinsey's)


"North West London CCG are paying for an international integrated care study tour from 29th November to 6th December to the US which will be attended by the CEO. Visits in Boston, New York, Baltimore and Richmond will be to innovative organisations who are renowned for excellent community care, integrated care and partnership models. Invitees to the tour include chief executives from acute and community providers and commissioners in the North West London sector. A report will be made to the next Trust Board meeting on the learning and outcomes of the visit."


Poorer financial performance than predicted


"The Trust’s financial position for the month was a surplus of £1.8m which is an adverse variance of £1.6m in month. The Year to Date (YTD) surplus of £0.8m represents an adverse variance against plan of £8.0m. Pay expenditure shows an adverse YTD variance of £18.9m as a result of under-achievement of CIPs, which are behind plan by £12.1m (53%) and the higher than planned bank and agency staff. Significant work is underway to look at our rostering practices across the Trust".


Complaints increasing


"There was an increase in volume of formal and PALS complaints in October."


Increase in length of stay for unplanned admissions in October


"the non-elective length of stay measure worsened in October to above the threshold of less than 4.5 days, to 4.9 days."


Reduction in theatre utilisation


from 77% to 74% in October.


Unpredicted variance in A&E attendances leading to longer waiting times

p 31

Following the closure of the Hammersmith Emergency Unit as planned. The subsequent number of attendances at

the St Mary Hospital and Charing Cross Hospital sites has been as expected from the modelling that took place

prior to the closure. However, there has been huge variance in the volumes of patients attending A&E, particularly

at St Mary’s Hospital.

Variations in attendances between days can be as high as 120. These unprecedented surges in activity have

resulted in the Trust failing to meet the 95 per cent four-hour waiting time standard.


Measures Imperial taken to improve A&E waiting times

p 31

" The focus for the Trust is to action a targeted response aimed at boosting resilience. There are a number of

initiatives now in place which will improve the waiting times.


Senior decision makers

The Trust has put in place additional GPs in the Urgent Care Centres, Emergency Nurse Practitioners, Intaking

Physicians, A&E consultants and management and nursing support. This will improve the pathway within the

emergency departments and reduce the time it takes for a clinical decision on the treatment options.


Physical capacity

The Trust has opened up extra capacity at St Mary’s hospital to accommodate an increase in medical admissions.

The Trust is also in the process of completing some estates work to accommodate additional ambulatory care and

Urgent Care Centre capacity at the Charing Cross.


Delays in Referral to treatment (RTT) targets missed

p 32

There is currently a national amnesty on delivery of the three RTT standards. This has been put in place and

agreed at a national and local level to allow Trusts to clear as many over 18 week patients as possible to add

resilience into the system going into the winter period. The Trust has put on additional capacity to treat long

waiters and therefore a dip in performance is expected. This applies to data submitted for performance in October

and November. In October, as planned, all three standards were under delivered. As well as putting extra capacity

in some challenged specialities to reduce the numbers of patients waiting over 18 weeks, there have been a

number of data quality challenges that the Trust has experienced since the implementation of a new patient

administration system in April 2014 (Cerner).


Delay in cancer RTT and diagnostic waiting times


"In September the Trust achieved six of the eight cancer standards. The Trust under delivered on the 62-day first

treatment from GP referral standard. This was the result of a high number of patients being referred into the Trust

from other sites late in their pathways, plus a number of pathways being resolved after delays through the

summer period. The Trust also under delivered on the 31-day subsequent surgery standard as a result of a number

of delays caused by consultant absence over the summer period. It is expected that performance for both of these

standards will be recovered in Quarter 3.


The Trust continues to work with local providers to redesign their diagnostic pathways. This is to ensure that

patients are transferred to ICHT for treatment earlier in their pathways in order to reduce the number of shared

pathway breaches, the predominant cause of 62-day breaches for the Trust.


Diagnostic waiting times

The Trust has not yet submitted the data for the six week diagnostic standard (due for submission on Wednesday

19th November) but expects to under deliver on this standard in October. 


Cost Improvement Plans behind schedule by £12..1m 53%


"The main reasons for the YTD adverse variance are:


Cost Improvement Plans (CIPs) are behind plan by £12.1m (53%);


Staff pay costs are significantly higher than planned and with an increase in month, indicating that the

previously instigated controls and agreed financial recovery controls are not being implemented.


There is on-going dialogue with the TDA about the impact of the proposed Project Diamond funding reductions on

the Trust’s financial position in both current and future years. Any reductions in funding will mean that the Trust’s

I&E control total will have to reduce.


Vacancy rate increased fr om 12.59% and Bank & Agency increased to 11.9% in October.



Threat to emergency surgery at CX?


The committee received an oral update on the action plan for Emergency Surgery at Charing Cross noting that

Divisional colleagues were developing proposals for the end of December 2014 for a plan around investment

across the three levels of cover required for a 3-5 year period to sustain the Charing Cross Hospital emergency



p 222

"Dr Tracey Batten advised that a decision was required by the end of the calendar year as to whether emergency

surgery at Charing Cross Hospital was a sustainable service and if not how to ensure the service at Charing Cross

Hospital would be sustainable. Prof Jamil Mayet would produce a detailed action plan by the end of October 2014

and Dr Tracey Batten noted that a sustainable plan needed to be put in place for the next 5-6 years as the

Business Case would not be implemented until 2020.


Surgery & Cancer

Prof Jamil Mayet noted that elective surgery at Charing Cross had moved from a Consultant of the day model to

Consultant of the week. The recruitment of Junior Doctors remained difficult but the rota was being actively

managed although would become an issue in the middle of 2015 as the rotation procedure would change

with Junior Doctors being given community placements resulting in a loss to the Trust of 15 Junior Doctors which

would be mapped for discussion at ExCo. 


Call for less spin from Imperial (from a insider)

p 224

" Sir Gerald Acher stated that he had been very disappointed with the recent Trust press release which implied that the Trust

was doing well in the National Cancer Patient Experience Survey and suggested that the Trust needed to be open and clear

in its messages and not use "spin".


Bill Shields is frank about finance


"The month 5 figures indicated that there remained a year to date deficit despite improvement with issues around:


Increase in both temporary and permanent staff;


Increase in bank and agency and locum staff;


A lack of effective controls with ineffective delegation;


Capacity not returning to pre winter levels;


Issues with Cerner:


More money on implementation

Inability to collect activity data effectively


CIPs (which were the subject of a separate paper) being:


o Unrealistic;

o Based on income and not the contractual position;

o Undeliverable.


Plan to cut more beds


"He confirmed that there was already an outline plan in place which had started to be progressed and that there was a bed

reduction opportunity which could achieve another £0.5M saving."


Plan to identify non profitable services

p 237

"The Committee noted that the work would be likely to identify opportunities for services that were currently not profitable"




A&E performance in NW and Imperial Trusts, year to 16th Nov 2014

Latest data published Friday 21st November for the week ending Sunday 16th November.


Type 1 A&E Visits, online % of Patients waiting less than 4h:

  • Imperial at 77.5% in week ending 16th Nov; a sharp drop of 8%pts from the previous week  (see tab 'Analysis' rows 104-107, or the 'Wait Stats' attachment)
  • London NW even lower on 68.7%
  • Imperial ranked 131st out of 140 Trusts in England reporting Type 1 stats in week ending 16th Nov (see tab 'Latest week raw data')
  • London NW 2nd-worst in the country (139th out of 140)
  • All-London (88.7%) and All-England (89.4%) posted their near-lowest and lowest scores respectively since May 2013; the purple and green lines on the graph have been declining steadily since mid-September, pointing to a national problem; there is no similar dip in the last 18 months.


Type 1 A&E Patient volumes

  • Volumes have increased in recent weeks by c. 2-300 patients at both NW London Trusts, but are still well below the typical weekly averages of the last year (see tab 'Analysis' rows 33-36, or the 'Patient Volumes' attachment).
  • All-England vol rose from 275k in w-e to 283k in the last week, but the average over the previous 9 weeks was 282k so this is not unusual
  • The average weekly vol in June-July was 292k, with average weekly performance at 92.8%, again pointing to a deterioration in service rather than an increase in demand


Cerner IT system: problems were predicted

Ever since I started attending the public board meetings of Imperial College Healthcare NHS Trust, the IT system provided by US corporation Cerner has been under scrutiny at these meetings. Cerner was supposed to "go live" in April 2014, but to date it has been a problem, giving results for "work-in-progress" which have significant errors and omissions. This affects management accounts, as well as the clinical work. Anecdotal information says that data input and updating is slow and cumbersome, and users have been given insufficient support to learn. Some doubt that this is actually the best system available, or that the IT department have sufficiently customised it for the particular requirement of ICHT.

We all know that IT systems have bugs and take time to learn to operate, but this one has had a lot of criticism. It is said that the corporation which developed it was given huge incentives by the US government to sell it to one and all.

As usual the Americans look at healthcare efficiency through the lens of possible savings rather than quality, which why this article in the New York Times of January 2013 is called: "In Second Look, Few Savings from Digital Health Records"

Two large IT corporations, GE and Cerner paid for a 2005 report by RAND Corporation, which seems to have exaggerated the possible savings, but persuaded the Obama administration in 2009 to give stimulus money to encourage hospitals and doctors to buy the systems. Cerner's income tripled from $1Bn in 2005 to $3Bn in 2013.

Technology “is only a tool,” said Dr. David Blumenthal, who helped oversee the federal push for the adoption of electronic records under President Obama and is now president of the Commonwealth Fund, a nonprofit health group. “Like any tool, it can be used well or poorly.” While there is strong evidence that electronic records can contribute to better care and more efficiency, Dr. Blumenthal said, the systems in place do not always work in ways that help achieve those benefits.

John Lister's assessment of NHS CEO Simon Stevens 5-year plan

New NHS plans - forward view, frightening, or fudge?



The new NHS plans published yesterday ask for £8bn - more than any of the big three parties are offering - and offer £22bn of savings. But we've heard such promises before - where will they come from?


Will new NHS plans get us out of the woods? Image: Nicholas Tonelli / Flickr. Some rights reserved.


Simon Stevens’ Five Year Forward View document is being reported in much of the press as a call for an £8 billion increase in NHS funding by 2020, to facilitate a raft of other policies aimed at reducing demand on hospitals and improving efficiency.

Even those suspicious of Stevens’ history in the US private medical corporation UnitedHealth, and as a Blair aide in opening the NHS up to the private sector, should be pleased to see him raise the need for more funding – asking for considerably more than any of the main parties have yet proposed.

But his cagey interview on BBC Radio’s Today programme yesterday, in which he dodged questions on the role of the private sector and PFI, didn't help allay suspicions of some of his proposals. While his plans to reorganise local services are a long way short of a full-blown blueprint for privatisation, it certainly offers the potential for private corporations seeking to leach profits from the NHS budget.

The report itself is evasively worded. It appears to focus mainly on NHS provision.

It defends - if a little tentatively - core NHS principles, saying “nothing in the analysis above suggests continuing with a comprehensive tax-funded NHS is intrinsically undoable”.

The briefings around Stevens’ proposals are significantly different from the Report itself. The £8 billion figure does not appear in the 39-page document, and nor does the accompanying figure of £22bn further “efficiency savings” (or demand reduction) that the Report says will be needed to bridge a £30 billion projected financial gap in NHS funding.

£30 billion is the widely agreed ‘gap’ between resources and demands for the NHS over the five years from 2015, if coalition spending plans to freeze funding in real terms prevail. The three main parties are living in denial.

Stevens’ report correctly points out that ‘flat funding’ along these lines ignores population growth, and could result in a reduction in real funding per head.

Stevens points to the astonishing success of the NHS in largely maintaining services despite the spending freeze since 2010, and acknowledges the sheer effort and dedication of staff that has made this possible.

But he glosses over the fact that a third of the apparent “savings” since 2010 have been at the expense of massive reduction in real terms salaries of the million NHS staff whose pay has been frozen since 2009.

It’s clear to all but Jeremy Hunt that another five years of the same cannot be delivered.

Stevens gives a brief nod to pay, suggesting “as the economy returns to growth, NHS pay will need to stay broadly in line with private sector wages in order to recruit and retain frontline staff”.

If this means more pay, it will require considerable new investment.

As will promises to:

·        Radically upgrade prevention and public health

·        Give “new support” to 1.4 million full time unpaid carers whose efforts keep the NHS afloat.

·        Give “resources and support” to the introduction of “radical new care delivery options” throughout England – among them new “multispecialty community providers” bringing together GPs, nurses, community health services and mental health, employ hospital consultants, run community hospitals and have admitting rights to hospital beds.

·        Give more NHS support for frail older people living in nursing homes.

·        “Invest in new options for our workforce, and raise our game on health technology”.

 But where will the money come from? Many of these are good ideas, but the price tag is never discussed.

Stevens claims that some of the investment will eventually deliver record levels of efficiency savings. But he doesn’t explain how.

Take the plan for “multispecialty community providers”. This is an even more ambitious revival of Lord Darzi’s controversial plans for “polyclinics” that were resoundingly rejected by most GPs and by local communities seven years ago. Despite government pressure only a few, expensive and unsuccessful, Darzi clinics were built – and most of them have since closed.

Now, as then, Stevens offers no serious discussion of the costs of the new modern buildings, equipment and professional staff that would be required to deliver this.

The plan potentially hugely fragments services currently provided in hospitals, with GPs employing hospital consultants in much smaller localised units serving very much smaller populations. This might sound good - but Stevens doesn’t it explain how it will do anything to reduce costs.

He does at one point suggest a “pump-priming” by “unlock[ing] assets held by NHS Property Services, surplus NHS property…”

Stevens also offers us a diametrically opposed alternative to GPs employing hospital doctors - that in some areas, Foundation Trusts in some areas could begin to run primary care, becoming “primary and acute systems”.

Stevens worryingly compares these with “Accountable Care Organisations” now developing in the US and “other countries”, often under private ownership.

He also offers “Clinical Commissioning Groups” the option of “more control over the wider NHS budget, enabling a shift in investment from acute to primary and community services.” Stevens ignores the reality that far from being “led by GPs” as he suggests, most CCGs are largely run by managers or by Commissioning Support Units and management consultants.

And he sets out hopes that prevention and health promotion changing people’s behaviour and lifestyle to reduce the demand for hospital care.

We’ve heard most of this before.

A shift from hospitals to ‘the community’, ‘alternative settings’ or ‘closer to home’ has been set out in every plan for hospital ‘rationalisation’ in the last 20 years or more - underpinned by the assumption that more localised services would somehow be cheaper. But there’s no evidence they are. As a result, even as local acute hospitals are undermined in the teeth of local opposition, community health services remain desperately under-resourced and further fragmented by repeated outsourcing and contracting.

And few GPs - except the most entrepreneurial - want to deal with the administration required to deliver such models.

More health promotion and prevention of ill-health is obviously a good thing. But it’s hard to change ingrained behaviour. Many of the health promotion targets have been wildly unrealistic, and the resources allocated to them completely inadequate. Time and again the burden of ill health among older adults that has already resulted from previous decades of less than healthy diet and behaviour has been underestimated.

There is no quick fix. Hospital attendances and admissions have risen throughout this same period - compounded by the massive cutbacks in social care, which are set to continue under Osborne’s public spending plans.

The result: intensifying pressure on the remaining hospital services - now taking the form of huge, under-funded demand on A&E, lengthening waiting times, and more delays in discharging patients from hospital for lack of suitable support in the community. A recent report in the Times shows the decline since 2010:

·        The number of people waiting for operations has gone up by one million to 3.3million people.

·        People are now waiting on average 10% longer for treatment.

·        The numbers waiting over 18 weeks and over 26 weeks for outpatient appointments and treatment have gone up by 25%.

·        Cancer treatment targets have been missed for two successive quarters.

·        For well over a year A&E departments have been failing to hit targets for treatment within 4 hours.

·        Trolley waits for a bed have almost trebled in the last three years.

·        Last minute cancellation of operations last year hit the highest level for nine years.

·        Delayed discharge of patients fit enough to leave hospital have hit a new record level.

·        60% of patients have to wait more than 48 hours to see a GP.

Both hospitals and GPs are clearly under huge pressure. Before doing anything that could undermine them, new services have to be put in place to ensure patient care is improved. This needs money and will take time.

Some of Simon Stevens’ ideas may help - if there was money to pay for them. But - whilst the three main parties have professed their welcome for Stevens’ plan, none have pledged to increase spending by anywhere near the £8 billion above inflation he says is needed by 2020.

And it’s unclear how his plans would generate anywhere near the hugely ambitious £22 billion savings target he sets.

Given this, his plan lacks credibility.

It’s noticeable that none of Stevens’ proposals to boost efficiency takes on the costly and wasteful elephant in every CCG and Trust boardroom – the inflated transaction and overhead costs of running the NHS as a competitive market.

Instead, his plan leaves room for private sector inroads that would further destabilise struggling and indebted NHS Trusts and contribute nothing of value to patient care.

Campaigners will have to fight on for genuinely alternative plans for the NHS. We need a short term increase in funding - followed up by efficiency savings based on stripping away the wasteful bureaucracy of the market. And we need longer term plans to get the rich and big business to pay their fair share of tax towards public services we all need, but which are being starved of resources.