Four years of “special measures” have apparently achieved little or nothing in the crisis-ridden Worcestershire Acute Hospitals Trust, whose two A&Es have been branded “inadequate” after an unannounced inspection by the Care Quality Commission (CQC) in December.
This is an abrupt reversal from the previous CQC rating last September which as a result of an inspection in May declared that the troubled Trust’s urgent and emergency care had improved from “inadequate” to “requires improvement.”
This in itself was a surprise, following immediately after intervention by NHS Improvement, also in May, to implement a series of Enforcement Undertakings after finding the Trust was failing to operate efficiently, economically or effectively, and failing to ensure its services were safe. NHSI imposed a plan on the trust for it to take ‘all reasonable steps’ to recover its position.
It’s not clear what changes the CQC might have detected that NHS Improvement had not seen.
However, it is now obvious to all that the trust, centred on the PFI-funded Worcestershire Royal Hospital, lacks the necessary capacity to deal with winter pressures. The Trust’s January Board meeting heard that “core occupancy” rates at both its Worcester Hospital and the Alexandra Hospital in Redditch had been running at 100%, and this resulted in notoriously long delays in handover times for emergency ambulances, with 797 delays of over an hour in December alone, up more than 50% from December 2018.
One patient died in December after being kept waiting for an hour in an ambulance outside Worcester’s packed A&E. In November one patient was kept waiting 11 hours in an ambulance – so long he had to be switched to another ambulance when the original crew ended their shift. His son counted 16 ambulances outside at the same time. Sadly such delays are far from new. In 2017 two patients died on trolleys in Worcester’s A&E.
The CQC’s latest report now also points to patients being treated in corridors “as standard” – a problem they noted back in 2017 – as well as overcrowding at the Alex.
However, the Trust has also been the victim of absurd planning and commissioning decisions by the CCGs, which produced a completely misguided Sustainability and Transformation Plan for Herefordshire and Worcestershire in 2016.
Rather than address the long-standing capacity issues in Worcester and Hereford hospitals, the STP prattled on about putting “… prevention, self-care and personal resilience at the heart of our plans”, and reshaping the approach to prevention, “to create an environment where people stay healthy and which supports resilient communities, where self-care is the norm, digitally-enabled where possible, and staff include prevention in all that they do”.
The STP aimed to reduce spending on urgent care and emergency admissions, and elective treatment for ‘non-life threatening’ problems, diagnostics, and medicines, in order to increase spending on maternity care, mental health, elective treatment for life-threatening conditions (cancer, cardiac, etc.) and extended primary and community services.
It proposed total closure of 202 community hospital beds and a net total of 55 acute beds, with all of these cuts in Worcestershire. It didn’t make any sense then, and it’s even more ridiculous now.
Far from seeing any reduction in need for emergency care, the Worcestershire Trust has been inundated with increased numbers of patients: its performance summary for December points out that it had been expecting 5% more A&E attendances than last December “but had nearer 7%;” emergency admissions were also up over 8% on last year across both sites – with nearer 17% more at the WRH site – much higher than the predicted 5.3% increase on December 2018.
Performance in 4 hour emergency standard, ambulance handovers, 12 hour trolley waits, and number of hours patients spent on the ED corridor all deteriorated in December. Occupancy remained above 92% even though the Trust discharged more patients daily than predicted.
Not surprisingly given the pressures, there has been an increase in absence due to stress/anxiety, worsening the staffing levels.
To compound the problem the chronically under-funded Trust is expecting to end the year with a deficit of “no more than £82.8m,” and has not signed up to the “control total” of £64.4m deficit set by NHS Improvement. In 2018/19 it needed £70m of revenue support to support the deficit position.
The Trust paid out over £31m on its PFI contract last year, bringing the total already paid for the £87m hospital and support services to over £420m, with another £370m still to pay until 2032. At the end of 2018/19 its finances were propped up by £113m of current loans (up from £42m the previous year) and £159m of non-current loans.
It’s clear that the combination of poor planning, poor decision making by commissioners, and a serious lack of adequate services in the community, coupled with a chronic lack of financial resources have left the Trust in an impossible position, and that so-called “special measures” accompanied by occasional reprimands from the CQC and NHS Improvement have been of little help.
Worcestershire is not the only trust in this type of situation: sadly, given the recent election result, it seems no significant change of approach is likely to relieve the problem in the immediate future.
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