Re­gion or­dered to im­prove its emer­gency units


TWO years after Greater Manch­ester signed its ground­break­ing health de­vo­lu­tion deal the re­gion has been or­dered to im­prove its A&Es by gov­ern­ment.

Lat­est fig­ures show all but one of our hos­pi­tal trusts are miss­ing emer­gency tar­gets laid down by White­hall under 2016’s deal.

Sev­eral lo­cal hos­pi­tals are also fac­ing mas­sive deficits while Greater Manch­ester coun­cils have raided £66m in re­serves this year to fund social care.

It is a sit­u­a­tion that has raised sig­nif­i­cant ques­tions over whether min­is­ters gave our re­gion enough money to pay for the new sys­tem in the first place.

One hos­pi­tal trust has de­scribed ‘ex­treme’ and ‘im­mense strain’ on its A&E be­cause of ris­ing num­bers of frail, el­derly pa­tients with com­plex con­di­tions re­quir­ing a lot of med­i­cal at­ten­tion and a longer stay in hos­pi­tal.

In some ar­eas ex­hausted staff, com­pletely com­mit­ted to their com­mu­ni­ties, are strug­gling to cope.

Greater Manch­ester’s de­volved health sys­tem took ef­fect on April 1, 2016, with its terms stat­ing that 85pc of pa­tients must be seen at A&E within four hours.

Be­low that level, gov­ern- ment has the op­tion to ‘step in’ and take the reins.

De­spite a range of other im­prove­ments since de­vo­lu­tion – in­clud­ing in cancer and stroke care – in Fe­bru­ary the re­gion’s fig­ure stood at 83pc.

Two lo­cal trusts, Stock­port and Wi­gan, ranked in the bot­tom 10 per cent of per­form­ers na­tion­ally.

Jon Rouse, the re­gion’s chief health of­fi­cer, con­firmed that, the­o­ret­i­cally, na­tional health bosses could ul­ti­mately choose to in­ter­vene as a re­sult.

He said: “There are trig­ger points within the sys­tem which if we fall be­low – de­pend­ing how far we fall be­low – NHS Eng­land can ei­ther re­quest an im­prove­ment plan or, in ex­tremis, they could de­cide to in­ter­vene and step in to the sit­u­a­tion.”

Greater Manch­ester had been in breach of its fourhour tar­get ‘for some time’, he said, adding that while its per­for­mance was not un­usual in terms of the na­tional pic­ture, its de­vo­lu­tion deal makes it unique.

“Only Greater Manch­ester is under a de­vo­lu­tion agree­ment with this type of ac­count­abil­ity stan­dard and I think NHS Eng­land have made a judge­ment that it’s rea­son­able to ask us for an im­prove­ment plan,” Mr Rouse said.

“Given that we’re not behaving very dif­fer­ently from the rest of the coun­try, I don’t think they’re in a po­si­tion where they’re con­sid­er­ing ‘step-in’, but they want to know what we’re do­ing to try to im­prove the sit­u­a­tion. And from my per­spec­tive that’s fair enough.”

The ‘prin­ci­pal driver’ of the sit­u­a­tion had been high num­bers of med­i­cally sick pa­tients need­ing ur­gent hos­pi­tal care, he said, adding: “The is­sue is the num­ber of peo­ple with high acu­ity com­ing in the front door over the win­ter pe­riod.”

How­ever, he pointed to three underlying chal­lenges faced by the re­gion in im­prov­ing emer­gency wait­ing times.

Many of Greater Manch­ester’s A&E units are age­ing and phys­i­cally too cramped, he said, and while some ‘lit­tle bits of cap­i­tal fund­ing here and there’ have been pro­vided by gov­ern­ment, a new bid for money is now be­ing drawn up so the de­part­ments can han­dle ‘a to­tally dif­fer­ent num­ber of peo­ple’.

“Some of the A&E de­part­ments are just too small for the num­ber of at­ten­dances and the pa­tients with high acu­ity com­ing through them and that is a real prob­lem,” he said. At the same time, in com­mon with other parts of the coun­try, Greater Manch­ester had strug­gled to re­cruit front­line staff, he said, adding: “The third is­sue is our over­all fi­nan­cial sit­u­a­tion.”

Four trusts – Stock­port, Tame­side and Glos­sop, Pen­nine Acute and the men­tal health provider Pen­nine Care – are fac­ing par­tic­u­larly ma­jor fi­nan­cial chal­lenges, he said. Tame­side re­ported a £22m deficit at its last board meet­ing, while Pen­nine Acute’s North Manch­ester Gen­eral was look­ing at a £13m short­fall.

Men­tal health provider Pen­nine Care has not pub­lished its pa­pers for March.

Board pa­pers for Stock­port NHS Foun­da­tion Trust, which runs Step­ping Hill hos­pi­tal and has con­sis­tently strug­gled with A&E tar­gets in re­cent years, show it pro­ject­ing a £36m deficit next year, which will see it rely on emer­gency fi­nan­cial fund­ing via NHS Im­prove­ment. They also show the scale of the pres­sure faced by its A&E de­part­ment.

“The trust has con­tin­ued to ex­pe­ri­ence ex­treme chal­lenges to op­er­a­tional per­for­mance with sig­nif­i­cantly high lev­els of at­ten­dance in the emer­gency de­part­ment in re­cent weeks,” reads an up­date to the board from its chair last week.

“This has re­sulted in ex­cep­tional strain on ser­vices which led to the med­i­cal di­rec­tor to take the re­luc­tant, but nec­es­sary, de­ci­sion to can­cel a num­ber of clin­ics and tem­po­rar­ily sus­pend train­ing in or­der to max­i­mize the clin­i­cal re­source avail­able to man­age pa­tient flow. The con­se­quence of these chal­lenges on our per­for­mance against the A&E four-hour stan­dard is starkly re­ported else­where in the board pa­pers.”

A spokesman for Stock­port NHS Foun­da­tion Trust said its hos­pi­tal has been ‘under im­mense strain for some time now’.

“A&E num­bers are up by 8pc and many of our pa­tients are frail and el­derly, with com­plex con­di­tions that re­quire a lot of med­i­cal at­ten­tion and a longer stay in hos­pi­tal,” she added. We have be­come bet­ter and faster at cop­ing with the surge in de­mand and opened ex­tra beds, but there is no easy so­lu­tion.

“We are sorry that de­spite the huge ef­forts of our hard working staff, only 65.3pc of A&E pa­tients were ad­mit­ted to a bed within four hours last month. It is im­por­tant to point out how­ever that ev­ery­one is re­ceiv­ing safe care.”

The trust is also mak­ing ‘con­tin­u­ous’ sav­ings and try­ing to treat more peo­ple at home, she added.

Ever since the de­vo­lu­tion deal was signed, many se­nior po­lit­i­cal fig­ures have feared it could be un­der­mined by lack of cash, par­tic­u­larly in the face of the on­go­ing squeeze in coun­cil­funded social care.

Bar­bara Kee­ley, Labour’s shadow min­is­ter for social care, said: “Tory min­is­ters of­ten hold up Greater Manch­ester as an ex­am­ple of progress in in­te­grat­ing health and social care.

“How­ever, Greater Manch­ester started out with a black hole in fi­nances for both the NHS and social care. If the Tory gov­ern­ment wants to make a suc­cess of de­vo­lu­tion in Greater Manch­ester, they must also find ad­e­quate fund­ing to tackle some of the chal­lenges we face.”

Bury-born shadow health sec­re­tary Jonathan Ash­worth said: “Eight years of fi­nan­cial squeeze, eight years of se­vere cuts to lo­cal author­ity social care bud­gets and eight years of fail­ing to re­cruit front­line clin­i­cians we need are all com­ing to­gether now into a perfect storm - and it’s pa­tients who are suf­fer­ing the con­se­quences.”

De­spite the pres­sures in A&E, Jon Rouse said two years of health de­vo­lu­tion had brought sig­nif­i­cant ben­e­fits. While some trusts are fac­ing se­vere cash dif­fi­cul­ties, the sys­tem as a whole is set to record a small sur­plus for 2017, he said, as it has the pow­ers to move money around in a ‘ma­ture’ way thanks to de­volved pow­ers.

Cancer treat­ment tar­gets had been met most months since the de­vo­lu­tion deal, an achieve­ment ‘which isn’t the case in most parts of the coun­try’, he pointed out, and one that had taken ‘a huge amount of work’.

“On stroke care I think there’s a very good story to tell,” added Mr Rouse. “We’re now the high­est rated acute ser­vices in the coun­try - all of them are ‘a’ rated. So if you have a stroke in GM you can be con­fi­dent that which­ever of our stroke ser­vices you go to, you’ll get in­cred­i­bly high qual­ity care, which is some­thing we are very proud of that’s been achieved.”

Health lead­ers are now draw­ing up a strat­egy to get 90pc of pa­tients seen within four hours at A&E by the end of June as part of the im­prove­ment plan for NHS Eng­land.

A spokesper­son for NHS Eng­land North said: “It’s our role to mon­i­tor per­for­mance to en­sure pa­tients are re­ceiv­ing the safe, high qual­ity care they de­serve.

“Many sys­tems have faced chal­lenges this win­ter and where this has been the case, we have worked with lo­cal or­gan­i­sa­tions to re­solve is­sues through ap­pro­pri­ate mech­a­nisms.”

The then Chan­cel­lor Ge­orge Os­borne, right, and Sec­re­tary of State for Health Jeremy Hunt on a tour of NHS fa­cil­i­ties fol­low­ing the ground­break­ing £6bn Greater Manch­ester bud­get deal

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