Written Ministerial Statement
The content of this written ministerial statement is as received at the time from the Minister. It has not been subject to the official reporting (Hansard) process.
Department of Health, Social Services and Public Safety- Emergency Departments in Northern Ireland
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Published at 12.00 noon on Tuesday 18 March 2014
Mr Poots (The Minister of Health, Social Services and Public Safety): The purpose of this Statement is to update the Assembly on the progress being made on a number of actions across the Health and Social Care sector aimed at ensuring the safety and quality of services provided by our emergency departments. It is important that the public is aware of this work so that it can have confidence in the services being provided in our emergency departments and across health and social services more generally. I specifically want to update members on what is happening at Belfast Trust and also at Lagan Valley and Downe Emergency Departments as well as a range of wider actions being taken forward.
Members will recall that in my Statement to the House on 10 February I advised that I had commissioned the Regulatory Quality Improvement Authority (RQIA) to do two things in response to the issues identified within the Emergency Department of the Royal Victoria Hospital which would help ensure that the Belfast Trust and wider Health and Social care system could act as effectively as possible on those issues and ensure a full and open process of review.
Firstly, I instructed RQIA to carry out an inspection of the Royal Victoria Hospital Emergency Department and Acute Medical Units over the weekend of 31 January to assess the quality of care and dignity afforded to patients. Secondly I asked that RQIA conduct a wider review of the arrangements for unscheduled care within the Belfast Trust and for regional co-ordination and escalation.
Regarding the inspection which was carried out over the weekend of 31 January, members will recall that the initial feedback in relation to the issues identified within the RVH caused me to have serious concern about whether the Belfast Trust was consistently performing to the high standards that I and Assembly Members expect, whilst recognising however that some of these are wider issues that cannot necessarily be addressed by the Trust on its own.
The RQIA has advised that they will provide me with a final report of their inspection in early April. Crucially, this report will include a Quality Improvement Plan which will set out the proposed actions of the Trust to address the findings of the RQIA Inspection, and further work which may be required.
I can however inform the Assembly that the Belfast Trust is already in the process of taking forward a number of actions in immediate response to the feedback they have received. These include an urgent review of nurse and medical staffing levels in both the Emergency Department and the Acute Medical Unit which has now been completed. Additional nurses have been appointed on foot of this, 15 to the Emergency Department and 25 to Acute Medical Unit. The Trust has also appointed a dedicated clinical co-ordinator senior nurse for the Acute Medical Unit.
Exploratory action has also begun to identify any immediate opportunities to improve the flow of patients out of the Emergency Department as well as to and from the Acute Medical Unit with the aim of reducing pressures there.
The Trust is also working to ensure the key functions of the Acute Medical Unit and specialist Units in relation to patient intake are understood with clarity; as well as reviewing the timings of key meetings to ensure that specialty triage decisions are taken as early as possible.
Further the trust is examining what immediate actions it can take to reduce the number of patient in outlying wards.
Ensuring that patients are properly tracked throughout their hospital stay is also a key area of work that the Trust is taking forward. At present all patients are tracked on the Patient Administration System however the Trust plans to implement an electronic tracking system as rapidly as possible.
This is in addition to work that had already commenced following receipt of a report from the College of Emergency Medicine in November 2013 in response to an inspection which the Trust had commissioned. Changes already introduced following that report include:
- establishment of a new Directorate of Unscheduled Care with a Director, Associate Medical Director and Medical lead tasked with leading improvement and modernisation of urgent care within the Trust. A Reference Group chaired by the Medical Director brings together senior doctors from all the relevant specialties to advise and support this process;
- two Emergency Department nurses will undertake training as Advanced Nurse Practitioners, which will mean that they will be able to provide some services in the Emergency Department which would traditionally be undertaken by middle grade doctors. It is the Trust’s intention to support more;
- a Programmed Treatment Unit (PTU) is now in place on the Royal site to provide treatment for patients which would previously have required them to remain in hospital;
- establishment of an Emergency Surgical Unit (EMSU) on the Royal site to ensure the early involvement of surgeons in the management of cases presenting to the Emergency Department. I understand that this has already had an impact in reducing waiting times in Emergency Department whilst providing much more timely surgical care for surgical patients. It is worth noting that this particular development has received a Quality Award from the Institute of Healthcare Management;
- the role of the Acute Medical Unit has been expanded to include input from Acute Medicine and Geriatric Medicine consultants aimed at providing senior medical care more rapidly to medical patients;
- the Trust has also piloted a Programmed Treatment Area in the Emergency Department, which enables ambulatory diagnostic assessment of patients who might otherwise be admitted, and they are working with the Health and Social Care Board to develop a regionally agreed approach.
The actions I have outlined are in direct response to the recommendations emanating from the inspections. However, a number of other changes are currently being implemented within the Trust with a view to enhancing the flow of patients through the system and ensuring quality and safety of services. These include:
- The establishment of an Acute Medical Assessment facility within the Acute Medical Unit to allow much earlier intervention for medical patients presenting to the Emergency Department. Patients referred by their GP for possible medical admission will be assessed here rather than in the Emergency Department. This will enhance the service already available on the Belfast City Hospital site;
- The Trust has also piloted a successful “Acute Care at Home” service headed by a consultant which can provide care at home which previously would have needed hospital admission. This is in line with developments as part of the Transforming Your Care changes.
These actions are specific to the Belfast Health and Social Care Trust but I would look to the HSCB and the PHA working with the Trust to ensure that lessons learned and best practice are shared more widely across not just the Trusts but also in primary and community care settings which are vitally important in ensuring the effective operation of our Emergency Departments.
We have seen significant improvement in the number of 12 hour breaches. Regionally there has been a significant reduction in the number of patients who have waited longer than 12 hours - from September 2013 to January 2014, 558 patients waited longer than 12 hours compared to 2,248 during the same period last year, a reduction of 75%. This is welcome but it needs to be built on and improved. Clearly there remains much to be done to ensure delivery against the 4 and 12 hour targets that I have set for EDs.
Emergency Department performance continues to be a focus of engagement by the Health and Social Care Board and PHA with Trusts and I continue to look to the HSCB to work with Trusts to ensure the necessary improvements are made.
One example of this is work being undertaken by Commissioners to improve the flow of ambulance borne patients to all acute sites. The Health and Social Care Board has worked with NIAS and BSO to develop a web-based dashboard with indicators measured against agreed baseline activity, which provides an indication of ED pressures and in turn informs patient flow decision making for Ambulance-borne patients.
Initially this development is focusing on the following six major acute Type 1 Emergency Departments: Altnagelvin, Antrim, Craigavon, the Ulster and the Mater. The dashboard is due to go live in April 2014.
The HSC Board has also provided funding to NIAS to appoint Hospital Ambulance Liaison Officers (HALOs) in Emergency Departments to help improve ambulance turnaround times. Feedback from Trusts on the effectiveness of these staff has been very positive with noticeable improvement in hospital turnaround times. The HSCB has therefore extended the funding for HALOs for a further year while a full evaluation takes place.
Regarding the wider RQIA review of the arrangements for unscheduled care within the Belfast Trust and for regional co-ordination and escalation I am pleased to inform the Assembly that the review team which will be led by Dr David Stewart, the RQIA Director of Reviews and Medical Director, has now been appointed, and will include the following members:
- Professor George Crooks, OBE, the Medical Director of NHS 24. Professor Crooks will be contribute expertise in examining the links between primary care/ ambulance service and hospitals;
- Dr Alistair Douglas, President, Society for Acute Medicine – consultant in acute medicine in Dundee, who will offer his expertise in management of Acute Medical Units;
- Kathy Fodey, Director of Regulation and Nursing, RQIA who will offer expert assistance in nurse education;
- Paul Harriman, Assistant Director, Service Improvement, Sheffield Teaching Hospital – who has been involved in a major patient flow project in Sheffield teaching hospitals and will bring this experience to bear in looking at patient flows through the entire system;
- Dr Taj Hassan, Vice President, College of Emergency Medicine. Dr Hassan will bring his considerable experience as an Emergency Department consultant in Leeds;
- Mary Monnington, Independent Nurse Advisor – Mary is a former ED nurse who has considerable experience of several similar reviews of emergency medicine;
- Dr Elizabeth Myers, Nurse Consultant, Acute Medicine – will bring her expertise alongside that of Dr Douglas looking specifically at nursing issues in AMU;
- Professor Bill Reid, Dean of Postgraduate Medicine, South East Deanery, NHS Education for Scotland – who will assist the Review team with examination of issues in medical education;
- Patricia Snell, Deputy Director Quality Improvement and Patient Safety, Guy’s and St. Thomas’ NHS Foundation Trust –will look at governance issues across the system;
- Mr Niall McSperrin – an experienced RQIA lay reviewer
As regards the Lagan Valley and Downe hospitals I made it very clear that I was deeply disappointed that the South Eastern Trust had decided to close the emergency departments of those hospitals at weekends; however I accepted the Trust’s difficulty in recruiting middle grade doctors or securing locum cover.
Although it has been necessary to temporarily reduce the opening hours of the emergency departments of the Lagan Valley and Downe Hospitals, I have challenged the South Eastern Trust, the HSC Board and the Department as to why this change has proved necessary, particularly during the winter period and I have asked for several key actions to be taken.
Firstly, that all appropriate and feasible steps are taken to ensure that the consequences of these changes are managed in a way that minimises the risk of unmanageable pressures on the emergency departments at the Ulster, Royal Victoria and other affected hospitals, so that patient safety and the quality of the patient experience is not compromised. The Trust and the HSC Board have assured me that the numbers of attendances and admissions likely to arise at other sites will be manageable.
I have been advised that GP Direct admissions are working well for Lagan Valley and Downe. At Lagan Valley, to date on average three patients are being admitted at weekends from the GP Out of Hours service and a further four are being admitted directly as a result of other non-elective admissions i.e. transfers from other hospitals. With regard to the Downe Hospital, on average nine patients are now being admitted at weekends from the GP Out of Hours and a further two as a result of other non-elective admissions. A learning event was held between the Trust and Lisburn GPs on 27 February 2014 to further engage GPs and a key focus of that event was the direct admissions process. The Trust will continue to refine the process in conjunction with GPs.
In respect of the repatriation of patients from other hospitals to the Downe and Lagan Valley Hospitals, the Trust report good cooperation from the NIAS and that there is effective repatriation of patients where clinically appropriate.
The South Eastern Trust recently launched a pilot minor injuries unit in the Downe Hospital at weekends and will pursue similar provision for Lagan Valley Hospital. The Trust is currently recruiting Emergency Nurse Practitioners and a number of its own nursing staff are currently completing their specialist practice Emergency Nurse Practitioner programme through the University of Ulster. They are due to complete the programme in May 2014 following which they require a minimum of 4 months supervised practice working as nurse practitioners with minor injuries patients before they can practice autonomously.
The Northern Ireland Medical and Dental Training Agency (NIMDTA) recently met with the Trust. It had no concerns with training and deployment of junior doctors in Lagan Valley and Downe as a result of weekend ED closures. NIMDTA indicated greater levels of supervision are now in place in ED across the 5 day service.
Secondly, I asked the HSC Board and the Trust to accelerate the work to develop and implement the new model of care at the Lagan Valley Hospital which will enable many of those affected by these changes in the short term, to resume receiving services locally.
Work on the development of a Business Case for the implementation of the new model of care at Lagan Valley Hospital is ongoing.
Thirdly, I have asked that fresh efforts are made to secure medical staffing for both sites;
The Trust recently concluded a recruitment drive for Emergency Department Staff – ED Consultants, Middle Grade Doctors and Emergency Nurse Practitioners. I am pleased to advise that the Trust received a number of applications for their Consultant posts and are concluding the recruitment process. Unfortunately no applications were received for the Middle Grade posts. In terms of the Emergency Nurse Practitioner posts, these applications are also being processed with a view to appointments in the near future. The Trust continues to work with recruitment agencies and will attempt to recruit again in the open marketplace.
In addition to this, I asked the HSC Board and the Trust to bring forward a detailed plan for the future of the Downe and Lagan Valley Hospitals with an implementation plan, to secure confidence in the community that the best possible steps are being taken.
My Department will shortly be engaging with the Health and Social Care Board and South Eastern HSC Trust in respect of proposals for the future model of both the Lagan Valley and Downe Hospitals.
As I have said on a number of occasions the problems which manifest themselves in our emergency departments are not issues for consideration in the context of the emergency departments alone but need to be considered from a “whole system” perspective. Often the best solutions to the pressures in Emergency Departments are found outside the emergency room. It is vital for example to ensure that we have effective procedures in place to ensure that patients are properly and appropriately discharged. We cannot have a situation where people are discharged too early, or with inappropriate support and care packages which results in a readmission some days later. Nor can we have a situation where valuable beds are being occupied by patients who no longer need to be in hospital, but are delayed because of lack of capacity to support them in the community or their own homes.
Recognising this, and as part of the RQIA’s three year programme, a review of the effectiveness of our hospital discharge arrangements has recently commenced. This will play a key role in informing the outcome of the RQIA’s review of unscheduled care. The care provided to older people in acute wards be inspected across Northern Ireland as part of the three year review programme. I expect to receive the report later this year.
All of this work will need to be drawn together with other work across the HSC and my Department to develop a strategic approach to addressing the quality of care patients receive in Hospitals.
In all of this work it is vital that we share good practice and lessons to be learned not only within the Health and Social Care sector here but across the NHS and more widely. For that reason I am pleased to advise the Assembly of a major summit which the College of Emergency Medicine has agreed to hold in Northern Ireland on the 9th April. This summit will bring together policymakers, key leaders in health and social care across NI, as well as staff who work on the front line and senior colleagues from across the UK to take a whole system look at our unscheduled care systems.
This “invitation-only” summit will ask attendees to discuss examples of best practice which they have been involved in and to share their experiences, views and ideas through a number of workshops including:
- Access to Unscheduled and Emergency care: and ensuring an integrated whole-system approach;
- Improving Patient Flow and preventing Exit and Access Blocking;
- Sustainable Workforce models and the challenges of providing 7 day services
Underpinning each of the workshops is a drive to deliver safe, effective and high quality services to the people of Northern Ireland.
The College has also agreed to work with colleagues in my Department and the wider HSC to hold a follow-up event sixty days after the summit to build on the outcome of the summit and develop recommendations on how to maximise the effectiveness of urgent and unscheduled care services in Northern Ireland.
My officials will work closely with the HSCB and wider HSC as well as with the CEM and others to draw together the outcomes and recommendations of all of these strands into an action plan to improve the quality of unscheduled care services in Northern Ireland.
Effective workforce planning is fundamental to ensuring we have the right staff in the right place to deliver safe and effective services for patients and clients both now and in the future. My Department has appointed the Centre for Workforce Planning to carry out a review of the medical workforce, including undergraduate intake levels. The output of this work will provide the strategic context for how the medical workforce is expected to evolve. It will highlight the key issues for the profession and identify emerging patterns. This will better enable the Department, the Trusts and the Universities to plan future delivery and ensure the workforce aligns with the direction set in TYC.
At an operational level there are several strands of workforce planning underway: these include specific workforce planning reviews for Nursing and Midwifery, and Medical for primary and secondary care.
I recently attended an Emergency Care Summit to take the valuable opportunity to hear the views of frontline emergency care practitioners and hear firsthand how the current situations facing Emergency Departments impact on both the patient and on staff.
At The Summit I had an opportunity for both myself and the Chief Nursing Officer to engage in an interactive discussion with the audience who were frontline staff and we were able to hear their concerns in relation to emergency departments and also their views as to how these concerns might be addressed.
Their concerns primarily addressed professional issues which centred on career pathways and access to training and professional development opportunities for nurses who wished to work in Emergency departments. They also highlighted issues around staffing levels and recruitment and retention of staff with appropriate skills for an emergency care setting and the associated pressures that this caused to staff.
I am therefore happy to inform you of the following measures which will address the issues which were raised at the Emergency Care Summit.
The Chief Nursing Officer is commissioning work to develop a Framework for Emergency Care Nursing. This work will be led by the RCN Emergency Care Network, chaired by a member of the Network and supported by NIPEC.
The Chief Nursing officer will also take forward a review of the Baseline Emergency Staffing Tool (BEST) which is a workforce planning tool that has been developed by the RCN Emergency Care Association and the Faculty of Emergency Nursing, by incorporating it within the current work stream of Workforce Review and Planning which is currently ongoing.
I am under no illusion that it will take time to make a difference. I don’t expect change to happen overnight - but I do expect progress to be made. It is clear that there has been progress to an extent but much more needs to be done and we need to maintain the momentum that has been built. As I have said before these are complex issues and there are no easy solutions. In addressing these issues it will be important that we support and demonstrate our confidence in, the dedicated and committed staff who continue to deliver these vital services for our citizens on a daily basis.
