APPENDIX 7
Memorandum submitted by Llandough Hospital and Community
NHS Trust
STRUCTURE OF
SUBMISSION
1. This briefing note offers an overview of the emergency
admission problem and measures taken at Llandough Hospital and
Community NHS Trust to respond to this. It details a number of
generic issues regarding emergency admissions, then focuses on
the specific actions taken over the last year or so within the
Trust, before concluding by detailing the specific areas of investment
planned as a result of the recent allocation of £250,000
to the Trust through the recent allocation of additional funding
to the NHS.
EMERGENCY ADMISSIONS-WIDER
CONTEXT
3. Emergency admissions must not be considered in isolation.
This is but one part of the Trust's agenda, albeit a very significant
part.
4. As an integrated teaching, acute and community organisation,
the Trust is already known for the quality of its relationship
with the primary, community and social services sectors. With
this background, and in anticipation of the forthcoming White
Paper on the reform of the NHS and the managed market, the Trust
has already refocused its activities to deliver more long-term
agreements, reduce bureaucracy and increase partnership.
5. The strength of these relationships has also significantly
assisted the Trust in responding to the year-on-year management
of emergency admissions, by participating actively in transferring
the focus of care from the secondary to the primary sector wherever
possible and appropriate. Its development of Community Mental
Health Teams and Primary Health Care Teams and the early development
of Telemedicine-based services are a sign of this commitment.
There is an alternative viewpoint however. This states that the
pressures facing secondary care organisations (eg maintaining
access for all emergencies, meeting Patient's Charter and waiting
times standards, etc) are incompatible with the professed change
of focus, and crucially, resources, towards a primary care led
NHS. Many colleagues within the Trust would certainly agree that
such a renewed focus can only be accompanied by either or both
of new resources or a, politically unlikely, acceptance that secondary
sector organisations can no longer guaranteee to meet both PC
targets and projected volumes of emergencies. This is influenced
by a related factor, impacting on the ability successfully to
move towards a primary care driven NHS. This is the funding of
social services. As will be demonstrated, below, problems in this
sector have damaging consequences for NHS hospitals where beds
are inappropriately blocked by patients not in need of such acute
care. The knock-on effect for emergency capacity is obvious and
wellknown.
6. Emergencies can be greatly affected by the quality
of the process management within Trusts and Llandough Trust has
spent a great deal of time reviewing its clinical and managerial
processes. Equally fundamental, however, are the overall resources
available to address the issue. In this context the extra funding
made available across Wales is both necessary and helpful. However,
WAC members should note that the Trust is projecting a significant
year-end overspend (probably in the region of £1.9 million,
as reported to the Welsh Office Health Department at the end of
October 1997) and is also discussing with its commissioners how
best to address a major year-on-year shortfall on its revenue
budgets. With this in mind it should be remembered that the Trust
has this year overseen a significant further reduction in its
management and administrative costs and staffing levels. In that
we believe that the Trust was already running a lean operation
these reductions will further impact on the Trust's capacity and
ability to respond to a range of strategic issues, including emergency
admissions.
7. Not least of the wider issues facing the Trust is
the Trust reconfiguration process. In itself this is not directly
related to emergency admissions. But the Trust adamantly believes
that its ability to offer a complete and effective service to
those in need of emergency admission will be greatly enhanced
if its future remains centred on being an integrated acute and
community provider. Allied to our relationship with our locality
commissioners, GPs and the Vale of Glamorgan Unitary Authority
we believe that our population will significantly lose out if
these strengths are ignored in Ministers' eventual judgement.
8. Other major areas of operational activity include:
responding to NHS Wales Planning and Priorities Guidance to improve
the health of the people of our catchment area; working with Bro
Taf HA and other local organisations in delivering the Authority's
strategic plan, particularly the transfer of elective Orthopaedics
from Rhydlafar and the CRI; major site redevelopment to accommodate
Orthopaedics and the recent commissioning of the new Theatre suite;
major IM&T developments including upgrading existing clinical
information systems and preparation for the "Year 2000"
software problem.
9. The point to note through all of this is that the
Trust is facing a significant and growing agenda. These issues
affect clinicians, managers and support staff alike. Each of the
issues highlighted above can be regarded as having a significant
impact upon Ministers' priorities and upon the quality of services
offered to patients. Emergency admissions are recognised as being
a key priority for the NHS and are managed by the Trust accordingly.
But they remain only one item among the many major strategic,
and short-term operational, issues which the Trust needs to manage
within increasingly limited time and resource constraints.
EMERGENCY ADMISSIONS-SOME
GENERAL OBSERVATIONS
10. The Trust believes that research evidence is now
particularly clear about a number of points. These have recently
been usefully highlighted in the NHS Confederation document-"Tackling
NHS emergency admissions; policy into practice". In particular
we would wish, with the Confederation and others, to highlight
the following points:
- extra long-term funding for the NHS and social services
should be identified. This should extend into a review of funding
for long-term elderly care and the boundary between the NHS and
social service funding;
- initiatives for multi-agency local working must be encouraged
and strengthened;
- there are significant staffing and recruitment issues
which need to be addressed both locally and nationally. These
include staff morale but extend to the availability of appropriately
trained staff;
- initiatives to encourage nurse-led and non-medical,
clinician-led services in hospital and community settings should
be encouraged to ease pressures on emergencies within the secondary
sector and social services;
- increased pressures from emergency admissions can often
lead to "bed-borrowing" between clinical specialties
and to increased length of stays;
- any review of the existing "market-management"
mechanisms (eg existing NHS contracts) should focus on the need
to develop appropriate measures of emergency and elective hospital
treatment;
- Government and commissioning Authorities have to recognise
that Trusts are frequently being asked to manage the politics
rather than the reality of the situation. For example, and as
noted above, a frequent requirement on Trusts is to "profile"
elective activity to allow all emergencies to be treated, whilst
never "closing to take", yet still ensuring that there
are no breaches of Patient's Charter standards or guarantees.
All provider organisations attempt to manage this agenda. Generally
they are successful. But on those few occasions when all the balls
cannot be kept in the air there must be greater recognition that
it is sometimes an impossibility to do so. Instead there has been
a tendency towards sound-biting and reflexive "provider-bashing";
and
- in turn, this leads to a related issue. Even when Trusts
vigorously manage their elective and emergency activity it has
to be accepted that cases in both categories are rarely "like-for-like".
Resources consumed will vary with dependency, case-mix, length
of stay, support required, and so on. Thus, even where the numbers
can be made to balance between elective and emergency (not an
easy task) the resources consumed are very unlikely to be the
same. Emergency cases are generally more resource-intensive than
elective.
11. The Trust is keen to see a co-ordinated drive at
national and local levels to resolve the problems surrounding
emergency admissions at many levels:
- alternatives to admission should, wherever possible,
be encouraged. Llandough Trust already offers a range of services
which assist in this, such as offering GPs quicker access to clinical
tests and results, expert consultant opinions perhaps supported
by new technologies, and open-access service;
- community services developed as an alternative to admission;
and
- even in an emergency attempts can be made to plan admission
with a patient's GP until a hospital bed is available, often allowing
care at home for a crucial few hours.
12. Within hospitals experience shows that a number of
initiatives can ease the process. Llandough Trust has taken action
to apply many of these locally:
- capacity planning and demand scheduling. The Trust has
been piloting two systems of activity profiling and has demonstrated
that this can assist the flow of patients. However, there are
resource applications and existing information systems need to
be significantly strengthened before such planning tools can really
take-off;
- admissions wards. The Trust has implemented medical
and surgical emergency admissions wards (see below) and this has
significantly assisted its ability to manage this issue;
- the Trust has appointed a Bed Manager from within its
existing resources. This is making a significant difference to
the Trust's ability internally to manage emergencies and ensure
that beds are properly occupied and utilised. It is also a key
role in building links between local Trusts so that proper co-ordination
of inter-Trust patient flows, where necessary and clinically appropriate,
can be given effect;
- the Trust has increased its levels of day case work
over recent years and has also strengthened its ability to deliver
high dependency services-both of which developments will have
had some impact in slowing the increase in emergency admissions
or in taking pressure off general wards; and
- the Trust has also recently reviewed its discharge arrangements
and is developing a dedicated discharge lounge. Allied to a close
working relationship with the social services and other relevant
agencies it is hoped that this will ease the process of monitoring
"blocked-beds" for those patients no longer in need
of acute care and speed-up the search for alternatives.
LLANDOUGH HOSPITAL
AND COMMUNITY
NHS TRUST-SPECIFIC
ACTION TAKEN
13. Llandough Trust has been allocated £250,000
from the specific £2.318 million available to Bro Taf Health
Authority. The Authority, after discussion, specifically asked
the Trust to target the following areas:
- support services associated with the Emergency Admissions
Assessment Unit;
- increased capacity/activity ie additional beds at Barry
Hospital;
- primary/community enhancement for earlier discharge;
and
14. The Trust's immediate, prioritised, response to this
allocation is as follows:
| Bed Manager | | £12,000
|
| Bed Manager out of hours cover |
| £6,000 |
| Pharmacy (*fast trace service contribution)
| | £15,000 |
| Discharge Lounge: | 1.5 E Grade Nurse
| £9,000 |
| | 1.5 A Grade NA | £5,000
|
| | Furniture/refurbishment |
£15,000 |
| Appointment of four Porters |
| £10,000 |
| MEAU-Ward Receptionist | |
£5,000 |
| Consultant Radiologist | |
£10,000 |
| Various Equipment for MEAU |
| £50,000 |
| The Barry Hospital-Opening 10 Beds (staff) |
| £50,000 |
| (substitute GP cover for Staff Grade Doctor)
| | |
| | Non Staff Costs: Drugs |
£5,000 |
| | Other | £10,000
|
| Community/Therapy/Nursing Teams |
| £20,000 |
*The General Manager to investigate implementation of entire
service
15. All the above appointments and funding should be
implemented as soon as possible and will end as at 31 March 1998.
Discussions with the Authority are continuing and as yet unallocated
funding will be further prioritised to meet ongoing needs.
16. The trust had already implemented a number of specific
measures to address this issue:
- set up a Medical Emergency Admissions Assessment Unit;
- established a Pain Clinic to which GPs can send patients
suffering chest pains who would otherwise have been admitted to
hospital;
- the appointment of a Bed Manager on a secondment basis
responsible for ensuring minimal delays in admission and discharge
arrangements;
- provision of a Discharge Lounge in the planned admission
area, where patients can wait in comfort for their transportation
home;
- improved the response time in meeting the requirements
for medication for patients to take home;
- use of a special discharge ambulance to minimise delays
for patients waiting in the discharge lounge;
- a Medical Emergency Assessment Unit, to improve the
management of all medical emergency admission patients;
- a Surgical Emergency Assessment Unit, to provide a similar
service to surgical emergency admission patients as for medical
emergency admissions;
- provision of facsimile machines to wards, thus enabling
Pathology test results to be speeded up; and
- commencement of a review of the Radiology Department
to increase response times.
17. On average, 28 patients per week are eligible for
discharge, subject to appropriate continuing care packages being
put in place, but unable to be discharged because of the lack
of same. These patients remain in acute hospital beds within the
hospital and contribute to what has been known as inappropriate
bed-blocking.
18. The Trust presented the Authority with a number of
options to resolve these problems for the period until 31 March
1998, including the opening of 10 additional beds at Barry Hospital,
as noted above.
19. To demonstrate the year-on-year increase in emergency
admissions. One of the problems in any such comparative exercise
is deciding what currency to use. The Trust demonstrates a significant
increase over the last five years, whether using admissions or
deaths and discharges as the comparator. It is contended, however,
that the use of medical admissions offers the, most relevant comparator
of the pressure on the specific specialities affected and these
have been included for this reason.
20. As can be seen, there has been a significant year-on-year
increase:
- 1995-96 over 1994-95 11.26 per cent;
- 1996-97 over 1995-96 0.43 per cent; and
- 1997-98 over 1996-97 5.71 per cent (#).
[(#)-year to date straight-line profiled to year end, which
is likely to be a significant underestimate given that we are
now coming into the critical and high volume period for emergencies.]
CONCLUDING OBSERVATIONS
21. This synopsis has detailed the wider context underpinning
this Winter's possible emergency admissions problems. It has demonstrated
that the Llandough Trust has already given effect to a number
of innovative schemes to address the foreseeable problems. The
allocation to the Trust of £250,000 as recently announced
will allow the Trust to take a number of further but non-recurring
initiatives. The Trust has also demonstrated a close degree of
co-operation with other local organisations, in particular the
Bro Taf Health Authority, the University of Wales Healthcare NHS
Trust and various branches of the Vale of Glamorgan Unitary Authority.
22. However, Welsh Affairs Select Committee members are
asked to note that the recent allocation from the Department will
not by itself solve this problem. This paper has highlighted the
complexity of the issue and noted that a coherent and strategic
response is needed from the centre and that this ought-if all
priorities are to be adequately addressed-to be funded by new
resources. This has moved beyond being an issue of provider-,
managerial- or clinical-efficiency. Each of these issues must
still be addressed of course. But we would encourage the Committee,
and the Ministerial team, to recognise that the policy agenda
cannot continue as currently debated.
23. Some of the Government's own policies (eg as detailed
in planning and priorities guidance and in the Patient's Charter)
are mutually exclusive and contradictory. No amount of exhorting
managers and clinicians will change this fundamental dichotomy.
It is our belief, in a public service, that this debate should
be conducted openly and honestly and would commend this report
to the Committee in that regard.
Dr N H N Mills
Chief Executive and Hon Consultant
in Public Health Medicine
16 December 1997
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