Emergency Department consultants and matrons

23 November 2012
Mr Matthew Kershaw
The Trust Special Administrator for South London Healthcare Trust
Sir,
We are writing to you in our personal capacities as the senior clinical team responsible for the Emergency Department (ED) at Lewisham Healthcare Trust. Our ED was recently refurbished at the cost of £12 million, with the addition of an Urgent Care Centre (UCC) and an expanded Resuscitation room capacity
Your draft report regarding the future provision of NHS services in South-East London recommends the closure of University Hospital Lewisham’s (UHL) full ED. This is despite the fact that your position as Trust Special Administrator and the Unsustainable Providers Regime that empowers you, are specific only to the failing Trust you currently head and not to Lewisham Healthcare Trust.

UHL ED presently sees >115,000 attendances a year; predominantly from Lewisham, but also from Bromley, Bexley, Greenwich and Lambeth. Despite the fact that the Borough of Lewisham contains some of the most deprived areas in England, our hospital has regularly been one of the CHKS’ top 40 hospitals in England. Our ED not only serves its local population but has also been an invaluable (and regular) fallback resource for the London Ambulance Service and NHS London when neighbouring EDs have been forced to close their doors.

We have thoroughly perused your draft report and noted numerous inaccuracies, assumptions and misrepresentations. We can only guess that these are as a result of the hasty timetable employed. The intention of this letter is to point out several of the more glaring examples.
The assumption that 77% of our ED patients can still be seen in the UCC in future

  • Patients in UHL UCC are seen by a combination of ENPs, GPs and ED doctors between 0800 – 2400hrs (predominantly by ENPs and ED doctors); however between 2400-0800hrs they are only seen by ED doctors.
  • This means that patients are seen in our UCC department with problems far greater than those that can be handled in a typical UCC
  • A standalone UCC will not be able to handle the number or acuity of patients that we presently see.
  •  ENPs currently have the resource of ED doctors being available for advice and decision making, thus increasing the number of patients that can safely been seen and treated by them. In their absence they would need to transfer patients to a full ED rather than discharge them at the initial consultation. The ENPs have chosen to work in an integrated department and there are real concerns about the retention of this very experienced workforce and future recruitment.

Quite clearly, the 77% figure you have employed is not representative of any realistic future modelling.
The assumption that only 23% of our ED patients require admission, specialist intervention and/or referral to another (tertiary) unit

 

  • This does not take into account the approximately 6,036 patients per annum admitted to the Rapid Assessment and Treatment Unit (RATU) under the care of the Emergency department for periods up to 48 hours.
  • Consequently over 5% of our annual attendances have not been factored into the calculations provided in the draft report.
  •  It also does not take into account the 1,498 paediatric attendances/year who require admission to the Short Stay Unit in the Children’s ED

On review of our case mix, by our estimation at most only 30% of the total attendances to the present-day combined ED and UCC could be safely managed in a standalone UCC. The remaining 70% would have to be seen in an ED setting; there is no provision in the report as to how this could be catered for by surrounding services. Consultation with our neighbouring ED colleagues suggests that they do not have the capacity to absorb these numbers.
Inaccurate data in the draft report regarding our most unwell patients

  • The report claims that UHL ED receives on average 2 ‘Blue-light’ ambulance attendances per day. This figure is not derived from any data that we as a department have provided.
  • Lewisham ED receives on average 4-5 ‘Blue-light’ ambulance attendances/day. These verifiable numbers are derived from our departmental software which automatically logs all ED attendances.
  • The use of ‘Blue-light’ ambulance attendances as an indicator is flawed as it does not address the considerable number of patients admitted through other areas of the ED who subsequently deteriorate to such an extent that they then require transfer to our Resuscitation room.
  • Analysis of our Resuscitation room records reveals a daily average (2011-12) of 10-11 patients being admitted to the Resuscitation room for intensive/critical level care.

This is a far truer indication of the number of such patients who would need to be transferred to neighbouring EDs by ‘blue light’.
A blatant disregard for the ongoing high performance of Lewisham ED

  • Part of the justification used for placing SLHT under the TSA regime was that “the Trust has a record of weak emergency department performance failing to achieve the 4-hour standard in 2010/11 and 2011/12.”
  • In comparison, Lewisham consistently exceeded the 4-hour national standard

o We exceeded the old standard of 98% in 2009/10 (98.7% of patients seen)
o We exceeded the updated standard of 95% both in 2010/11 (98.2% of patients seen) and 2011/12 (96.4% of patients seen).

  • The ED at Lewisham was rated as the best site in London for training for GPVTS trainees in the 2010 PMETB survey and was in the top quartile of training sites in the same survey among F2 doctors.
  • It is recognised that this ED consistently performs well against national Clinical Quality Indicators. In addition monthly quality nursing audits have demonstrated the high standard of care that we deliver to our patients.

Disregard for the effects of the proposal on Lewisham’s educational responsibilities

  • Our trainees are unlikely to be sanctioned by the Deaneries and Colleges if there is no acute hospital service at the UHL site.
  • The loss of trainees would lead to severe challenges in providing physician cover for any proposed UCC, thus increasing our dependence on locum doctor cover.
  • UHL ED has had a relatively low dependence on locum doctors due to its strong educational record, which has proved to be attractive to both trainees and non-training grade doctors.
  • We also provide a training environment for pre and post registration nursing and medical students from Greenwich and Kings College Universities, which will be threatened by the loss of the ED.

We have to date managed to keep a largely full rota of substantive middle-grade doctors unlike many other London EDs and this will be destroyed by your proposals.
The assumption that 30% of the volume of work currently done in the ED will be transferred to the Community

  • This has not been achieved anywhere in the UK before. There is no robust evidence to support this claim (certainly it is not contained in the report or its appendices).
  • Such a change would require significant infrastructure and personnel investment.
  • There is no indication as to the facilities that would have to be put in place
  • There is no detailed financial costing of what is needed to achieve this

This claim is central to all your proposals but there is no evidence to support it. The future of acute care in South-East London cannot be based on aspirational statements and unfounded promises.
The suggested use of a ‘UCC plus’ model

  • As already pointed out, 77% of our ED patients are expected to attend the future UCC. This would rely on paramedics, ambulance technicians and GPs being able to determine before sending patients to the UCC that they will not require admission. These practitioners send their patients to an ED precisely because they cannot make this determination beforehand.
  • At the present time approximately 7 in 10 patients referred by GPs to the ED are managed by the emergency doctors who utilise hospital systems and services in such a way that they are able to be discharged home. This ability would be lost in a UCC of any variety.
  • A ‘UCC plus’ would still be deprived of a Resuscitation room; this would present a major risk to patient safety, given that a significant number of ED patients deteriorate after initial presentation to the GP/London Ambulance Service.
  • The proposed ‘UCC plus’ would have to function in the absence of a HDU/ITU; critical patients who deteriorate after initial assessment will therefore require transfer to another trust, yet another (unnecessary) risk to patient safety.

A ‘UCC plus’ is an untested model that shows no real advantage over other models in the absence of the other acute services you propose to cut.
Conclusion
Feedback from our patients, the public and colleagues such as the London Ambulance Service (LAS) tell us that this ED is incredibly well regarded, and that the public and LAS choose to come here. We believe the implications of this proposal are extremely serious and will detrimentally affect the care and service that is offered to our local community. Concerns over how our patients will be able to access acute services at QEH, and the inevitable impact on an overstretched LAS, have also not been adequately addressed.
It is our opinion that as the draft report has been based on demonstrably incorrect figures and assumptions, its findings cannot be relied upon. An issue as important as the acute care of patients in South-East London cannot be determined by a hasty and flawed process, which was never designed to be used to reconfigure NHS services.
We have no objections to change, and strongly support all moves that promote the safe and effective care of patients. Thus we strongly urge that the proposed merged trusts (QEH and UHL), the local GPs and the wider public be left to decide at a local level how our services should be reconfigured. This would not only be a safer and more considered, but would also be in line with the Government’s ethos of greater local control with a patient-centred approach to healthcare.
Yours sincerely,

ED Consultant
ED Consultant
ED Consultant
ED Consultant
ED Matron
ED Matron
ED Nurse Consultant

See Intensive Care Consultants’ response

See ENT Dr’s response

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