Shropshire's A&Es ‘are worst performing in the country’

Hospitals in Shropshire had the “worst performing” A&Es in England during the last week, it was revealed today.

Ambulances at Princess Royal Hospital in Telford
Ambulances at Princess Royal Hospital in Telford

The length of waiting times at the Princess Royal Hospital and Royal Shrewsbury Hospital were so great on certain days it put the trust that runs them at the bottom of a national rank of NHS hospitals.

Both were the lowest in the country at meeting the NHS target of seeing patients in A&E within four hours.

The problems are is believed to have been experienced on Thursday and Friday last week, although Shrewsbury and Telford Hospitals NHS Trust says it is unable to say how long patients were actually forced to wait.

The situation improved dramatically by Sunday, when 95 per cent of patients in A&E were seen within the prescribed time frame, with 323 patients using the emergency departments.

The news was revealed by David Evans, chief officer at Telford & Wrekin Clinical Commissioning Group. It comes after representatives from the county’s two CCGs and the hospitals trust, which runs both hospitals, attended a regional meeting to discuss recent poor performance in the urgent care system.

Mr Evans said: “A couple of days last week we were the worst performing system in the country, but a series of actions and improvements have been put in place this week. Last weekend saw both sites meet the target – we are seeing some progress but there is still some way to go.”

Last week it was revealed that 370 people visited Shropshire’s two main A&E departments on March 6, their “busiest day” so far this year.

and the trust said the same amount also attended both emergency departments this Monday. The week beginning March 6 was also the busiest week at the departments all year, with 2,405 people seen, the equivalent of 14 people per hour each day.

Royal Shrewsbury Hospital
Royal Shrewsbury Hospital

So far this year, as of Monday, the trust has seen 22,386 people in its emergency departments, an average of 307 people per day. New figures nationally revealed just 85.1 per cent of patients attending A&E were seen within four hours in January – making it the worst month on record.

Simon Wright, chief executive of the Shrewsbury and Telford Hospital NHS Trust, said it was indicative of the pressure that the NHS has faced nationally.

He described the regional meeting as “very constructive”

Mr Wright, who also chairs the Shropshire A&E Delivery Group, added: “I am pleased to say that in the week leading up to the meeting our A&E performance had improved due in particular to staff working incredibly hard to reduce the volume of non-admitted breaches.

“In order to maintain and improve performance, a number of measures were agreed which will be delivered through the Shropshire A&E delivery group, which meets monthly. These will focus on pre-hospital care, inpatient flow across Sath and Shropshire Community Trust, complex discharge planning and delays in ambulance handovers.

“As a system, we need to invest more of our focus into reducing ill health and the resulting admissions that then are needed in our hospitals.

“We also discussed plans to help with areas identified by NHS England and NHS improvement as a focus for avoiding similar problems next winter, in particular freeing up hospital bed capacity and managing demand for A&E services.

“Some estimates suggest that nationally, between 1.5 and 3 million people who go to A&E each year could have their needs addressed in other parts of the urgent care system, but turn to A&E because they are unclear about the alternatives or are unable to access them. That is something nationally, the NHS will be looking to address.”

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Comments for: "Shropshire's A&Es ‘are worst performing in the country’"

johnfrederick

When will the NHS services start telling the residents what is going on in Shropshire what they are going to cut and how big it is going be and how will we get a better service out of all of this ?

Roger

It seems to me that pursuing NHS standard models is not yielding anything and a local model is required to manage their three different work flows in different ways.

Three work flows;

1. Ambulance delivered to the major injuries unit.

2. Walk in to the Minor injuries unit/Urgent care centre.

3. Walk in to the GP unit.

The problem starts with triage. Patients presenting must be triaged to the lowest and correct unit. That means far more sent to the GP and they will not be proper to A&E statistics. Co location is a matter of geography. In Telford these patients would be referred back to their GPs because they were always GP problems and A&E is not there as overflow for GPs. These should be recorded as declined on presentation. If treated they should be recorded as not proper to A&E and counted separately.

Within the Minor injuries units/ Urgent care centres follow up appointments need to be better managed to avoid patients waiting whilst Doctors are doing appointments. Spread them out so that doctors can see walk in patients between appointments. Because patients wait whilst appoints are conducted they sit with the clock running for as long as it takes, reducing the doctors opportunity to treat within the 4 hours because at times the start time is already an hour or more into the 4 hours. Experience suggests that most of the time is wasted waiting for the Doctors. Once seen, treatment and discharge usually follows very quickly.

Make better use of paramedics and nurse practitioners. It does not follow that everybody needs to see a doctor.

If tests are going to be required this should be established at triage and patients tests conducted in advance of seeing a doctor. Tests like x rays could have the effect of down grading management from a doctor to a nurse practitioner. In my experience patients attend A&E out of an abundance of caution. If they hurt themselves they do not know the extent of the damage and a GP can not x ray it. So they go to A&E to have it checked out. What feels like a broken bone often is not. They are legitimate patients but may not need the attention of a doctor, or could be moved to walk in GP queue once diagnosed. The clock would stop once transferred to the GP queue. In some cases they should have gone direct to the GP queue and the GP could order the x ray and escalate based on results if required. In that case they should never have entered the A&E queue if the GP could handle it.

Bring Shrop Doc into A&E so that out of hours GP cases can be dealt with directly. To me there is no difference between the walk in GP and Shrop Doc other than home visits and the reception system. They are both GP overflow systems and not proper to A&E. However by being based within A&E patients proper to GPs can be diverted to them. That would cause patient frustration if was just pass the parcel but not if it seamless within the same clinic.

A fourth work queue is required for the patients proper to South Staffordshire and Shropshire Healthcare NHS Foundation Trust. This would include all their patients or potential patients who can only be addressed by the South Staffordshire and Shropshire Healthcare NHS Foundation Trust. They are not waiting for Shrewsbury or Telford Hospitals because they are not allowed to treat them if it is a mental health issue. Typically this might be a recovering Addict who's prescription has failed. The trust issues prescriptions on a Friday and no prescriber is available then before Monday. They only work office hours. The addict will be desperate and agitated, even entering withdrawal. Without doubt they need attention but A&E staff can not deal them. When refused they will become agitated. The same situation arises with drunks with a drinking problem and other mental health issues. There is no out of hours service available for these people so they will end up in A&E but are not proper to A&E. They should be placed in a separate queue, preferable a separate room and referred to South Staffordshire and Shropshire Healthcare NHS Foundation Trust for them to attend to. This issue is a NHS failure to provide out of hours services but not one proper to S&T trust so needs to be excluded from the statistics. How South Staffordshire and Shropshire Healthcare NHS Foundation Trust deals with them is their problem. All we can say now is that there is a problem but not S&T's problem. There will also be genuine patients attending A&E for injuries which the Doctor thinks need to referred to the mental health trust. The time should stop when treatment for the injury is complete and they are transferred to the fourth queue. It is neither fair or reasonable for other patients to be exposed to the behaviour of mental heath patients. Nor is it fair or reasonable that mental health patients absorb the time of A&E Staff to the neglect of others. It needs sorting out.

Other wider issues are not within the control of A&E but are proper to the system. Bed blocking and lack of cubicles have no instant resolutions so do not relate to the performance of A&E. It seems reasonable to me that statistics should be collected on these events and published along side A&E Statistics. They are problems which relate mainly to political money management and should be identified as such with equal publicity. All cases for delays beyond 4 hours should be classified with a cause code. It could be political lack of investment, it could be a catastrophic event, it could be lack of staff or bed blocking. Without understanding the causes solutions are not possible. Publishing the reasons separately fails to produce linkage. We often know the reasons for failure so they are proper A&E statistics. Often published in other returns without connecting the external failure back to the A&E stats. We need more comprehensive statistics to improve identification of cause and effect.

I think we have to accept that there is a failure in the Universities and Training Establishment to adequately supply doctors. A further problem once qualified to retain them. Problems with certain specialities exaggerated by the lack of supply allowing doctors to pick and chose what specialities they follow. The skills shortage is caused by many things some of which are political and if resolved today will have no meaningful effect for at least seven years. There is no clear indication that these problems have been addressed.

It therefore follows that we will need to operate A&E services with less Doctors for the foreseeable future. Amalgamating A&Es is not the solution if it takes the same number of man-hours to do the same tasks. It could improve speciality care but in essence it does not reduce the need for doctor man-hours. Therefore we must establish better methods of by passing doctors in the care delivery system by better use of non doctors. Nurses and pharmacists, GPs and Physiotherapists. They need improved training to specialise in A&E scenarios. Better use of reception facilities, including triage, 111, and receptionists to route patients into the correct queues for attention by the lowest appropriate grade without grade slip. We must not have under qualified staff treating but treatment at the right grade.

A lot of that is about how the patients reaches the right gateway to the NHS. The way it is set up with nurse led urgent care centres in the community hospital and availability of GPs to support them through peripatetic GP services. The way GPs use community hospitals to do things they would normally refer to a District Hospital. Geriatrics for observation or recuperative care, minor surgery and short term respite care.

Care needs a bottom up approach retaining as much as possible in the community by the better use of community hospitals. Never better illustrated than urgent care centres. It is a bottom up decision on what needs to done in a District hospital not a top down direction which does not consider community capability which will be different everywhere . But there should always be a gateway that the public recognise as a local gateway to which patients can enter the system and be treated or passed up the system as required. 24 hour attended by a nurse practitioner with call out facilities as required. Women giving birth can go there and meet their Midwife etc. They need beds but only within a multifunctional mode with isolation for contagious patients.

From a patient or carer point of view they are incapable of anything more that the simplest diagnosis so they need somewhere they can go 24 hours a day to hand over the situation to the NHS and the NHS take it from there. Ambulance attendants should have multiple choices in where they take casualties dependant on their assessment. Community Hospital, GP or District hospital and in conjunction with the patient and hospitals different destinations. I.E. a patient from Ludlow might prefer to go to Hereford rather than Shrewsbury of Telford and the hospitals may need to divert patients if they are saturated. I.E. a Patient in Newtown might go Aberystwyth to get treatment faster than Shrewsbury. Or to a call out Doctor at Newtown Community Hospital. Patients in Oswestry could clearly go to Wrexham if that is the best option. Bridgnorth to Wolverhampton. It should be a dynamic decision making process. There is no case for combining A&E s if the destination A&E has neither the staff or size of A&E unit to cope. You can move staff but not cubicles and beds. Physically the hospitals were designed to work one way and have to be adapted to work a different way and that costs money on which there must be a pay back to justify change for change sake. NHS models are idealistic but not practical outside the scenario they were developed in. E.G. the distance between A&E verses deterioration en route. If you start from hospital 10 miles apart when that changes to 80 miles apart the model does not work. Each scenario is different and divergence from the model essential if patients are not to suffer. The patient service starts from the patients home not the hospital door. The end product is a universal service but the delivery system can't be standard if circumstances are different. You can end up with a post lottery which is not a universal service. Budgets are derived from what it costs to deliver at a standard not the other way round. Start with demand and end at what it costs. If the budget does not cover the available funds then The Secretary of State must decide what service he will not deliver or increase the budget. Post code lotteries based on local decisions are not acceptable. The NHS should be the same service universally.

Derp

This is a controlled demolition of the NHS by the Conservatives. They have squeezed funding, sacked nurses, doctors and then used the media to attack it when these services have inevitably struggled. Then, they either close down hospitals, services or give contracts to private companies under The Health and Social Care Act 2012. The Health and Social Care Act 2012 was the privatisation of the NHS.

johnfrederick

Roger Patients by taken to Wrexham are put at the back of the line and we have to wait 2 days to get our Ambulances back ?

Roger

Wrexham has it's problems but there no reason why they should not be addressed. If it was not for the diabolical roads and lack of facitities in the right quantities Mid Wales could use Wrexham a lot more than it does now. Equally if it the patient that is the priority and Oswestry is in the process of doubling it's population then Wrexham has a role to play in the Shropshire scenario. It's not NHS England so not considered within the STP.

We do know that when the Mother and Children Unit moved to Telford many Mid Wales mothers to be elected to go to Wrexham rather than Telford. and that put pressure on Wrexham. The same could be true of Oswestry mothers to be . 13 miles to Wrexham or 35 miles to Telford. "IF" the init returns to Shrewsbury even that is 20 miles to travel.

The same can be said of people in Ludlow looking toward Hereford for services. If the service is in Telford then Hereford is closer and single transport hope down the A49 or on the train. Of course Shrewsbury and Hereford are equidistant. We have a generalised problem of not enough facilities on not enough sites. The solution are not restricted to Shropshire and Mid Wales being served the way they have been traditionally. The solutions may well be out of Shropshire and will be decided by patient choice. If they ever sort out Wrexham's problems then it could be much more attractive to Salopians. The roads from Oswestry and Whichurch are better than the A5.

Not really considered is the scope to expand Gobowen Hospital which has all the specialits on site to deal with a wider range of services for the North West of the county. No reason why it should not have Urgent care centre included or anmy other Community Hospital functionality. It could most certtyainly manage most Major injuries ot stabalisation of casualties before transfer to Shrewsbury od Stoke. It really is only a matter of how the STP considers the full range of options. Without any doubt Oswestry is the worst provided for secondary level town in Shropshire and it growing at an extraordinary rate. . I am not at all sure that Oswstry's issues are being addressed within the STP in the right way. The object of the exercise is not to look at where we are but where we are going.

According to the Midland's Connect programme publish last week they have the A5 upgrade pencilled in for planning in the late 2020's and upgradfe work in the early 2030's. Their main concern being road linkage between Birmingham and Holyhead. In my view that leaves Oswestry lookin north in communications terms and therefore needs it's hospital services looking north rather than toward Shrewsbury or Telford. The STP board are however rather more narrow minded than that. Their considerations are Shrewsbury and Telford Hospitals with everything else with GPs. I think that is fundamentally flawed because it fails to address the patients needs properly. In my view Community hospitals are key to rural environments and small towns as cluster points for rural services. Oswestry is a particulatr problem because it does not have a community hospital just a very good health centre. That is not going to meet Oswestry's needs going forward. They need to look at all options, including improving Wrexham.

veritycross

Blimee Roger!!!

Forget all the bumph - they, the Powers that be - appear to believe that one of these 'A&E's' should bite the dust. And here we have it, a national disgrace. Isn't there a saying regarding the 'proud Salopians'. You should be ashamed. So should our very own Shropshire MP Phillip Dunne whose current job description indicates he should be overseeing all this debacle, in Shropshire and nationwide.

Roger

Sorry you read it that way. My point is that with the best will in the world the "cock ups" have happened. There are not enough A&E specialists to go round. I can agree with you that it is disgraceful that we find ourselves where we are and blame must be attached. That looks very much to be in the decisions made by politicians over the last seven years. Their solution would be privatisation and I reject that totally. The basic concept of the NHS is the cheapest and most effective means of delivering health care. As someone put it we had a first class system funded at second class rates but now we have a second class system with fourth class funding. That is political, but for sure in the private sector it would a first class system at double the costs to treat only those who can afford it with a fall back fifth class system for those can't. In my view if we just went back to where we were in 2010, it would be better than where we are now, but to do that will take a long time because we have a created skills shortage and it is getting more difficult to fill the gaps with overseas recruitment.

It will take a minimum of seven years to bridge the skills gaps. So what do we do in the mean time? We have failure now so how do we mitigate it short term whilst fixing it long term?

My definition of efficiency is doing the same things with less resources, where as the politician's definition is to do less, thus use less resources. Clearly the way it is set up politicians issue real terms cuts and leave it others to decide what services to cut. We the people want no service cuts because health is too important to cut.

Top down reorganisations are based on management models in theory based on research into best practice thus delivering efficiency. Lansley's top down reorgainsation was not based in best practice but political dogma to privatise the NHS which would cost the government considerably less, but the public twice as much or more. The government would only be paying the private sector for a fifth class treatment for the uninsured and this would reduce the size and cost of government, which is the dogma.

My comments above are about how we manage to mitigate failure in the short term.

As a business the NHS is probably the least efficient business I ever seen. It's quality has been variable over the years but is basically good but not so good now. If we take an accountant based system for improving efficiency we end up with Stafford and we we do not want to go there. That said the cure for Stafford has only led to closing local services and bringing on failure in Stoke by overloading services there. We don't want that either. The solution is to use standard quality improvement techniques, applied through a bottom up system which uses the knowledge base of the employees at the bottom. They in fact know what's wrong with the system and how to improve it but nobody asks them. So what you do is quality improvement projects using different subject areas in different places and use the output to provide best practice models to apply more widely. By looking at the same problem in both urban and rural areas we can differentiate the best practice guides for the different applications. Most business managers already know this but NHS managers can't apply it because they are too busy "change managing" to political models so basic efficiency fails to deliver in the NHS.

I take many different people to hospital and GPs, and of course use the system myself, so the time wasted waiting in the waiting room and experiencing the processes in my mind are like a time and motion study. What I see is lots of NHS staff working ineffectively. Too much paper being hand delivered and high skills being used on low skilled tasks. There is nothing in the Sustainability and Transformation Plans that address those issues except the creation of the major injuries units to focus skills and create centres of excellence. That does not in any way change the patient needs or address 90% of A&E work. Real solutions are in how we handle the 90% not the 10%. For that we need to address the failures;

Is the right person doing the right job to the maximum of the their skills.

Remove the propensity to to under use the skills of people,

Remove time delays by speeding up communications.

Better triage to direct patients to the right skills instead of leaving that to the Doctor which wastes his time and is double handling.

They need to look at every piece of paper delivered by hand to see if it could have been electronically recorded and sent electronically.

Work queue and management systems.

Ready access to records. Walk in GPs can't see the patient's GP records?? A&E doctors can't see patient records.

Labour had a project for converting the NHS to a paperless system but the Tories cancelled it because it was very expensive. Now they are trying to recreate it. Technology is ever changing so they can't keep up with it in such a large organisation with such a large distribution of data. They should not try. What they need is standard formats for data and a distributed system with high grade network management systems. The actual computer systems should be local data bases with standard interfaces. More about standard protocols not the actual IT kit.

It is basically the same problem that recurs throughout the NHS and are tackled by top down rather than bottom up management of failure. It needs to be reversed.

Start at the bottom to see what can be done at the lowest level with escalation pathways to the next level up. GP services in central London probably means walk in patients whose GP is miles away The patient works and lives in different place. Schools can be miles from home. There is critical mass to provide higher services at all GPs. The rural GP is dominantly dealing with his own patients but does not have the critical mass to hold hi tech equipment. There is no standard model that can be suitable for both. In cities there is no need for community hospitals but in the countryside the community hospital is essential to locate the equipment for use by GPs because clustering brings the critical mass together.

Maternity units in cities have all types of birth together. Consultants can attend mid wife led units in minutes. In the countryside the location of where to give birth is critical because that facility to call in the consultant is not there. Transfers by ambulance in labour are risky. As we know the destination must be within reach of home because when labour starts time can be limited and fifty miles is too far to go. Babies don't come to a time table. However if the birth is anticipated to have risks mother must go to the consultant before going into labour. There is no standard model of maternity units that suit both.

So it is with urgent care. Ideally should be delivered locally at the GP or community hospital but with rapid escalation to bigger better units if required. In the city go straight to A&E but in the countryside go to the nearest gateway and then escalation will be a matrix of solutions Depending on what the problem is and where the higher solutions are located. My GP in Shrewsbury has more than ten GPs so one is always available for urgent appointments and escalations, the poor GP with a part time surgery in Clun is living in a very different world and needs different solutions.

Therefore my statement that national models do not work here. We need local solutions and critical analysis of how the skills mix can be best used.

"Bottom Up" not "Top Down" What we need today is not what we need in ten years time. Evolution not Revolution. A long term plan is essential but management is how we get from where we are to where we want to be without losing services on the way. It is the failure to have a proper long term plan that we are dealing with. Anything up to five years is more or less real time change with existing facilities. Beyond 5 years we plan the shape of future facilities.

We can't combine our A&Es today because there is no facility large enough. That takes 5 years to deliver. We have had 7 years of no long term plan beyond privatisation so do nothing long term. We have gone 7 years and are not ready for change because we have not prepared for change. The STP is a five plan 2015 to 2020 but in 2017 we still don't know the direction of travel. That is a hopeless position.

So what can we do today to mitigate 7 years of failure. The STP is a long term plan deliverable between 5 and 10 years. Staff training and recruitment is deliverable between 7 and 10 years for degree entry grades and 5 years for vocationally trained entrants. So for the next 5 to 10 years we have to deliver with reduced resources. It should not be so but it is. We need to get on with it by separating the functions of real time changes and long term changes.

Even if we improved the budget for Adult Social Care we would still need to implement growth through recruitment, training and purchasing. Because the skills involved are lower skills that can be done much faster but at least a year before there is any impact at all on the NHS. The care of the elderly and disabled needs complete reshaping because it's failing. That would take five years so the sooner we start the better. If it involves new buildings it will take longer.

Lucky 13

Well AE will never change as long as you have drunks being taken in they take at least 5 hrs to sober up if not longer. What happened to friends takin them home. If you can't handle your drink don't drink , oh yes there are tons of people from other countries who are in Telford. And they don't have a go. They should be charged. There useing AE. Like a walk in centre. Then you get those that don't need to be there at all , so don't blame the hospital or staff for long waiting times. It's you the people. Who are makeing the long waiting times ,

Those that don't need to be in AE. And the ones that can't be bothered to get a gp. Or dentist it's the sheer volume. Of people attending AE. That's the cause of your waiting times

And gp patients being sent to the hospital for admission. Do they ever check if there are beds

No. And. Gp patients have to wait in AE. There less than amused with that again not the fault of AE or staff but the very people who send them to the hospital in the first place is at fault so all go ahead have a good moan because. In the not distant future. You will be going to rsh and not prh. Then you will all have something to moan about , so stop whinging It's a AE not a Drs surgery. Most don't need to be there anyway

Roger

Two issues here.

1. your right there are to many people gpin there who should mnot be. But in Shrewsbury the walk in GP sugery is co located so they shoul;d be diverted straight there and no count in the staistics.

2. The queues of ambulances and lack of beds is just and failure to meet demand. Probably caused by a lack of Adult Social Services. However nobody is admitted if they don't need to be. I suspect that some who should be admitted are in fact discharged because there are no beds. At the end of the day that happened because politicians got their policies and priorities wrong. The NHS is just trying to cope with the consequences of political mistakes. Most of those patients are not there because of any trivial reason and most of them don't want to there. If they fall it was because the government though saving penny was more important than the health and welfare of the elderly. That then cost them pounds.They even have to audacity to blame the families for not looking after them when the governmenyt's intent is that every works and they help out with the elderly parents and children.

Im sure mostr families would one of the to give up their job to look after their elderly but they can't afford it because pay and conditions have been driven down..

immigration and poverty are the reasons for non registration and again that's politics. The crisis is a political creation that only politicians can fix. A&E is the safety net under political failure and there is so much of that , that system is failing.

Natuerally the last people to blame are the NHS staff who are heros for trying to deal with everything thrown at them. They can't turn them way unless it is to adequate care.

tigger58

This is what you get when you vote tory