In this report I will reflect on the ongoing impact of Covid-19, on our efforts to restore the services that were affected during the first wave of the disease and on the root and branch transformational work we are undertaking to improve the experience of those who attend our Emergency Departments (ED).

Covid-19

We have all, on a personal and a professional level, had to adjust to Covid-19 as it has influenced every aspect of our lives. At the Trust, thankfully, we have seen a significant reduction in the number of patients with the illness and we remain grateful when people like Muthucumaru Yasocumaron, who was with us for 98 days, are full of praise for the care they received. The passing of the first wave allowed my colleagues to pause and reflect on their experiences, as our Lead Chaplain, Phil Wright did, when he put pen to paper for us.

While our inpatient numbers have fallen (at time of writing) the underlying infection rate is growing in Barking and Dagenham, Havering and Redbridge (BHR). Across London, the virus is no longer just affecting young people in their twenties and the concern is that it will start to impact the elderly and the vulnerable who will need hospital treatment. We have, according to the Prime Minister, reached a “perilous turning point” and there are “unquestionably difficult months to come”.

We are prepared if a second wave in hospital admissions materialises. Everything we do is underpinned by stringent infection prevention and control (IPC) measures. We receive wise counsel on this topic from Magda Smith, our Chief Medical Officer who is also our Director of Infection Prevention and Control.

Maternity

The IPC restrictions on visiting we have had to put in place – to protect our patients and our staff – have understandably caused frustrations. I am pleased we have relaxed some of the rules in our maternity department where visiting, during set hours, can now take place on our wards, before and after a birth.

In our neonatal intensive care unit, where the visiting hours for one parent at a time have been extended, Baljit Wilkhu and her colleagues have devised ways of keeping families informed, including the creation of digital baby diaries.

Another area of concern for our expectant mothers (that we are keeping under constant review) has been the fact their partners are not able to attend scans. Our scanning and waiting rooms are small and to adhere to social distancing guidelines, we need to keep the number of people in these areas to a minimum.

I am always happiest, writing this report, when I can use it to highlight some of the extraordinary people I work alongside. One such person is Maria Benedetti, our lead midwife for multi-ethnic empowerment who supports our BAME pregnant women. Maria’s life story is an inspiring one.

Blood testing

Another of the services impacted by Covid-19 has been blood tests. They are carried out in our hospitals and in the community, depending on how the patient is referred. If they are under our care, a test is available at one of the hospitals. We have launched an online booking platform, as well as a phone line, to ensure patients can access blood tests. Haematology and oncology patients have a dedicated (Covid protected) service, five days a week, where those in greatest need are prioritised and seen at the start of each day. We are also still seeing children under 12. Patients referred by their GP need to have their blood test at a community clinic.

Paediatrics

All of our significant service changes are captured on our website. These changes include the fact our children’s inpatient ward at King George Hospital (KGH) will remain closed through winter as it will continue to be used for critically ill adult patients. Magda Smith described this, at a recent meeting of BHR politicians, as a “Covid measure for Covid times”. We are planning to open a Children and Young People’s Assessment Unit at Queen’s Hospital. This unit is designed to keep children from being admitted, unless absolutely necessary.

Covid-19 testing

Since June, we have been swab testing our planned care (elective) patients, those admitted through ED and staff who exhibit symptoms. We have a drive through facility at KGH that is open seven days a week. The challenge is that the reagent needed for swabbing is being rationed and we cannot process all our tests ourselves. When we rely on laboratories elsewhere in north east London (NEL) there is an increase in the time between conducting a test and receiving the result.

In line with guidance from NHS England, we have offered blood tests (that determine if you have been exposed to Covid-19 and have antibodies) to our staff and our NEL partners.

A window of opportunity

This is how NHS England described the weeks before winter sets in, in a letter they have sent to health leaders. We share the NHS’s desire to accelerate the return to near normal levels of non-Covid health services, making full use of the capacity available. We also acknowledge that with the growth in community infections, it is an increasingly small window of opportunity.

Inevitably, our waiting lists have increased and our ability to deal with them has been affected by the strict IPC regulations we must follow. Of particular concern are those who are waiting more than 52 weeks for treatment. Our focus is on bringing our waiting lists back on track, as we prioritise according to clinical need. We continue to use the capacity that is available to us in the independent sector.

One of the barriers we face is the resistance of patients to enter hospital, with up to one in ten declining their appointments. Ray Potter wasn’t put off and his message of reassurance was particularly welcome. We have produced an animated video to highlight the safety measures that are in place.

A key to success in achieving our goal is our much-improved relationship with Barts Health and the Homerton. Together, we are resuming services as a partnership, across NEL. This collaboration is evident in the way we will consolidate surgery in temporary specialist centres. The scientific evidence shows this leads to better outcomes, more consistent clinical standards and shorter hospital stays. Under this plan, KGH will offer a range of surgeries including hysterectomies, tonsillectomies and hip and knee replacements.

Planned (elective) care

KGH has become our high volume, elective services site. We have well-established ‘green’ and ‘yellow’ Covid zones, with seven theatres in operation. KGH is handling 30 per cent more elective activity compared with the same time last year. We are looking to do more elective work at Queen’s where endoscopy is up and running and we will have access to six ‘green’ theatres. For day case and inpatient procedures, we are on track, by October, to reach 90 per cent of the level we were at for the same period last year and 100 per cent for CT, MRI and endoscopy.

Outpatients

We are continuing to hold our clinics virtually, and on the phone, to keep our patients safe and we delivered nearly 83,000 such appointments between March and August. Our most clinically urgent patients are being seen face to face in the hospitals. By October, we should reach 80 per cent of the level we were at when compared with the same period last year, and 100 per cent by November.

Cancer

We used the independent sector to manage the majority of cancer treatments we were providing during the first wave of the pandemic. As our vulnerable patients were not coming into the hospitals, our Living With and Beyond Cancer team found new ways of continuing to support them. compared with the same time last year, we are back on track when it comes to fulfilling the two week wait cancer target. It will take longer to recover our 62-day performance target, not least because it relies on our endoscopy service recovering fully. We have been improving month on month recently and should reach the target by the end of the year.

I am proud of the fact we are leading the way with the technology we offer those undergoing radiotherapy. Stephen McTaggart was one of the first patients to be treated with one of our upgraded machines that uses artificial intelligence to find the exact location of a tumour in a patient’s body. Siobhan Graham, our Head of Radiotherapy, oversaw the introduction of this improved treatment. 

Happy hospitals

We have set ourselves the rather audacious goal of becoming the happiest and healthiest hospitals in the UK. As a first step, we engaged with colleagues, via a staff survey and focus groups, to determine their experiences of the first wave of the pandemic and their vision of an improved culture. We learnt from this feedback that we achieve much more when our leadership is compassionate, we have a common purpose and staff at all levels are empowered to act. Our next steps, in the coming months, include co-designing with our staff our new Trust identity, continually improving the wellbeing offer to colleagues and ensuring the diversity of our organisation is reflected at senior levels.

When it comes to ensuring all staff are treated equally, all of the time, we know we have a lot more to do. Devesh Sinha, our stroke lead, wrote three blogs, in which he reflected on his experience of working in the NHS as a BAME member of staff.

Four-hour emergency access standard  

It is a target, created in 2004, that is embedded in the NHS Constitution and that is used as a key measure of how a Trust is performing. It is a target – 95 per cent - that we last hit, for one day, in June 2017 (for our Type 1 performances). Our highest performing month in our EDs at Queen’s and KGH was August 2016 when nine out of every ten of our most seriously ill patients (Type 1) were admitted, transferred to another provider or discharged within four hours.

The four-hour emergency access standard is a high bar that we have failed consistently to clear. We are determined to find a long-term, sustainable solution to what has been an intractable problem. We owe it to our patients who suffer when there are delays to their treatment.

We want to avoid being defensive; we want to correct that which we have control over; and we want to learn from our performance at KGH where we consistently do better. We also want to establish a full understanding of the broader context in which we operate, particularly at Queen’s.

The ED at Queen’s Hospital

When Queen’s was opened in 2006 the ED department was built to deal with 300 patients a day. In the last financial year, average daily attendances (by patients seeking emergency care) were 446. Interestingly, one in five of these patients lived outside of BHR.

The IPC measures we have to follow because of Covid-19 have further exacerbated the difficulties of treating patients in a built environment that is coping with 50 per cent more people than it was designed for.

The limitations of the available space will become more acute in the years ahead as the BHR population grows. It is expected to increase by 100,000 over the next decade.

The extra £4.1m of government capital funding that we received recently for the ED at Queen’s will help. It will be spent on providing Point of Care Testing and on expanding the current Rapid Access and First Treatment area.

We have also received £3m to be spent, in this financial year, on improving the KGH ED and providing dedicated x-ray facilities. A further £12m, subject to approval of a business case, will be available in 2021/22.

Primary care

Our boroughs suffer from a shortage of GPs and such shortages translate, inevitably, into avoidable attendances at our EDs. Barking and Dagenham have 34 GPs per 100,000 population; Redbridge have 37; and Havering have 42.

Elderly patients

We know that roughly one in five of our most seriously ill patients (Type 1) who attend ED are aged over 75 and half of them end up being admitted to a ward. We serve a significant elderly population and that has an obvious impact on our EDs. Of the 99 care homes in NEL that are primarily used for older people, 67 of them are in BHR. The majority of these (37) are based in Havering and it is also the borough with the highest rate of care homes per 100,000 older people (79.7).

Before the pandemic, 600 patients, aged 75 and over, were being treated each week in our EDs. We were dealing with one in three of them within the four-hour access standard. The development, with the North East London Foundation Trust (NELFT), of an acute frailty unit at KGH will help with this group of patients.

Ambulances

We receive patients from the London Ambulance Service and from the East of England Ambulance Service. In July, just under 5,000 of our ED patients were brought to us by these two providers and we see roughly 160 ambulances a day. Based on the latest London-wide data, Queen’s receives the highest number of ambulances in the capital.

Staffing

We are not alone in facing difficulties in recruiting and retaining enough ED medical staff to cope with the rising demand (our nurse recruitment has been more successful). The Royal College of Emergency Medicine has reported that emergency medicine has a high attrition rate from doctors in training, high early retirement rates for experienced clinicians and significant reliance on locum (temporary) clinical staff.

In July we had 82 medical staff in post (including 16 permanent consultants) and we currently have 38 doctor vacancies in our EDs. On average, we have 149 shifts each week that are filled by locums.

Culture

We know our culture needs to improve and that excellence in healthcare is dependent on good team working where all feel safe and have a voice. We also know our ED colleagues have dealt with almost constant winter pressures in recent years; the pandemic; and the ongoing, inadequate flow of patients through our hospitals.

To support them, and indeed all of our medical leadership, we are bringing in clinical psychologists and coaching for individuals and for teams. We will exploit our relationship with Barts Health and the Homerton to establish peer reviews so that our colleagues can benefit from the experiences and knowledge of others working at neighbouring hospitals.

A whole hospital improvement plan

We have one and its emphasis on the need for everyone to play their part reinforces the point that the four-hour emergency access standard isn’t just an ED problem. Our plan is completely aligned with the No going back manifesto we launched at the end of the first wave of Covid and with our desire to become world class, happy and healthy hospitals. 

We want to become highly reliable hospitals where we do the right thing every time, every shift, every day of the week. We want to reduce clinical variation. We will use real time data to help achieve these goals. And we will adapt our internal structures so that it is easier to both support and hold to account those who are running our hospitals on a day to day basis.

Our improvement plan has seven workstreams that will focus, among other things, on primary care and ambulance service protocols; on a patient’s journey through our hospitals until discharge and beyond; and on our workforce, including a refreshed recruitment focus and a review of medical rotas. It will, of course, address the critical issue of improving flow.

This ambitious plan has already attracted good clinical engagement. We now need to move from words on a page to delivery of concrete change. It is our intention to first stabilise, then improve, and finally, transform the ED experience of our patients now, and into the future.

Tony Chambers
Chief Executive
September 2020