Dear Councillor Whittington,
Jan Sobieraj has asked me as the Clinical Director for Theatres, Anaesthesia and Critical Care and a Consultant in Intensive Care Medicine to respond directly to your email of December 23rd concerning critical care services at Grantham in addition to the response I understand you have already received from Jan.
I apologise for the length of my response but think it is important to explain in detail the historical and current issues related to critical care support for the Grantham site.
I felt it would be useful to start by confirming the terminology used in relation to critical care:
- Level 3 critical care refers to what historically would have been intensive care and this provides the highest levels of support for the very sickest patients. In lay terms those that would be referred to as being on “life support” and in most cases will require advanced support for multiple failing organ systems (heart, lungs, kidneys etc).
- Level 2 critical care refers to what historically would have been described as high dependency care – so patients who require very close observation and monitoring and some patients who require a lower level of advanced organ support for only a single organ system.
- Level 1 care refers to patients who are sicker than those that would normally be cared for in a standard ward environment, who again may require higher levels of monitoring and observation and some more basic forms of organ system support.
- Level 0 care is that which would normally be provided for patients who need treatment in hospital but whose care can be delivered by a normal hospital ward environment and staffing. Level 3, 2 and 1 care are generally provided in specific clinical care areas and have higher levels of staffing in terms of numbers and staff training and competence and higher levels of equipment than normal wards, although some specific level 1 care may be delivered in speciality wards- such as coronary care units, specialist respiratory medicine wards etc.
In the past although the term Intensive Care Unit was used quite specifically, the term High Dependency Unit was used much less specifically and would refer both to units providing level 2 care as well as to units that provided only level 1 care. That lack of clarity was one of the reasons the more detailed and specific level 0-3 system was introduced.
Historically Grantham had a “Intensive Care Unit” but the unit was always very small in terms of the numbers of patients it treated and in 2002 significant concerns were raised externally. These related to both the small numbers of patients being treated in the unit and an excess mortality in that patient group. Following from those concerns a formal review of the ICU service at Grantham was undertaken in December of 2002 lead by the Mid Trent Critical Care Network (MTCCN) who are the operational delivery network for critical care covering Nottinghamshire, Derbyshire and the ULHT portion of Lincolnshire.
As a result of that review and based on ensuring patient safety and quality of care, the MTCCN report recommended that level 3 care on the Grantham site be limited to a maximum of 24 hours and that patients who required a longer period of intensive care support were transferred from Grantham to a larger critical care unit. From 2003, arrangements were put in place to transfer those patients to Pilgrim Hospital. After 18 months – in July of 2005 – a further review of the service was undertaken to assess the changes introduced in 2003.
This second review concluded that there was evidence of “slippage” in the maximum 24-hour period of level 3 care before transfer and that there were difficulties in arranging and carrying out transfers when they were required. The second review made a number of recommendations. The first being that patients in Grantham who required level 3 care were transferred out immediately once their condition had been stabilised and transfer could safely be undertaken. Level 3 care, other than for the period of time required for stabilisation prior to transfer, has therefore not been provided on the Grantham site for more than 24 hours since 2003, and since 2005 patients on the Grantham site who required level 3 critical care have had that care delivered by stabilisation on the site then transferred out to a larger critical care unit.
That decision was made based solely on patient safety and quality of care concerns and on that basis, I do not believe the decision required public consultation, although extensive discussions were held both within the critical care network and with commissioners about the change to the way the service was delivered. I can confirm that no resources or staffing were withdrawn for the Grantham site and the capacity to stabilise patients prior to transfer has been maintained in full. During this period, Grantham “HDU” has continued to admit and manage patients. The majority of these patients have only required care at level 1, but a small number of patients have continued to receive care at level 2 support on the site.
The 2005 report also recommended that the formal process for transfer of these patients was established and funded (funding was provided for the first year jointly by ULHT and MTCCN). The service initially remained based at Pilgrim Hospital, however after 1 year the service was moved to be based at Lincoln County Hospital and to provide a more robust model. This includes a service where Lincoln critical care consultants provide a 24/7, 365 day retrieval service for level 3 patients on the Grantham site. This means that consultants collect patients that need a higher level of care and bring them back to Lincoln where that care is available, rather than paramedics. This was and remains one of very few consultant delivered adult critical care retrieval services in the UK.
Between Jan 2006 and end of September 2016 (the most up to date complete data available) this service has transferred a total of 303 level 3 patients from Grantham to Lincoln County Intensive Care Unit, an average of around 1 patient transferred every 2 weeks. All of the patients have been transferred safely and there have been no deaths or serious adverse events during these transfers. The long term outcome for patients transferred to Lincoln from Grantham is at or above expected levels and is comparable to that for patients admitted directly to Lincoln ICU, compared with significantly worse outcomes when these patients were being managed at Grantham.
Historically there was no widely accepted guidance / specification for HDU/Level 2 care. But with the publication in 2015 of the Guidelines for Provision on Intensive Care Services (GPICS which was published by the Intensive Care Society in 2015 and acknowledged by all the major professional organisations involved in the delivery of critical care services) and NHS England’s Service Specification for Adult Critical Care Services – known as D16 – there is now specific guidance on the way level 2 and level 3 critical care should be delivered and what the requirements are for units that provide those levels of care. With the publication in 2015 of the GPICS and the subsequent D16 service specification all critical care services were required by NHS England to undertake a gap analysis against the guidance co-ordinated by the Critical Care Operational Delivery Networks and to develop plans to demonstrate how services would become compliant with the new requirements.
The analysis of the Grantham service identified a number of very significant areas where the current service fails to meet these requirements and most importantly, where there is no realistic possibility that those requirements could be delivered in the future. These failures to meet the requirements are not due to any change in the service provision at Grantham, but simply reflect the fact that the service in Grantham would never have met these requirements. The level of service provision what was appropriate and acceptable in the past is not appropriate and acceptable now but that reflects a change in the requirements not a change in the service.
The areas where the service does not meet the specifications includes medical staffing (Grantham has no consultants in Intensive care Medicine (ICM) and 8 would be required to run a compliant ICM rota, indeed no consultants who meet that requirement have worked on the Grantham site in the past), nurse staffing (for example in terms of the % of nursing staff with specialist Intensive Care Training and qualifications) and a number of the supporting services that would have to be in place on the site to support a compliant critical care service that the Grantham site doesn’t provide.
As the national guidance and service specification indicate that level 2 care cannot continue to be provided on the site, we had to recognise that and act to ensure that the service provision was in line with the most up to date guidance. I would emphasise this was not a local decision made within ULHT but a response to the requirements of the new national guidance. To recognise this, the name of the unit has been changed from “HDU” to Acute Care Unit (ACU). The unit will provide level 1 care and discussions are continuing to ensure as wide a range of treatments and support as can safely be delivered on the site is available (what is locally being referred to as Level 1 Plus) in order to maximise the number of patients who can continue to be treated in the ACU on the site and avoiding transfer out wherever that is reasonable.
There are no plans in place to remove either resources or staffing from the site and those staff who have in the past provided care on the “HDU” will continue to be available on the site to provide care for patients in the ACU. Our aim is to deliver care on the site whenever we can do that in a safe way that meets the required standards and to transfer off the site only those patients who will benefit from a higher level of care than the Grantham can provide.
I understand that the STP document refers to “moving of level 2 critical care/HDU beds from Grantham Hospital to Lincoln Hospital” which is understandably confusing but I think the STP document merely reflects what is already in practice being extended to patients who require level 2 care. The sickest level 3 patients whose care needs cannot be met in Grantham are already moved to Lincoln. In future and in keeping with the latest national guidance, that patient group is being extended from those requiring level 3 care to those patients who need true level 2 care and who need to be managed by intensive care specialists.
We have in conjunction with colleagues on the Grantham site and local GPs looked in some detail at the patients who have been receiving care on the “HDU”. The vast majority of these patients have only required a level of care that can continue to be safely provided in ACU and so can continue to be treated on the site. There are a small number of patients who have required a level of care that requires a formal level 2/3 critical care unit and these patients will be stabilised on the Grantham site before being transferred to a Critical Care Unit – most likely to be Lincoln.
In terms of commissioning arrangements, the CCGs and local GPs have been involved throughout the discussions regarding the HDU/ ACU at Grantham and both understand and are supportive of the plan and changes to commissioning arrangements are already in hand with finance and contracting. Currently the commissioning arrangements for critical care services are such that both NHS England (for specialist commissioned care) and CCGs )for locally commissioned care) pay an additional tariff for the critical care portion of a patients hospital stay. That tariff is based on the level of support a patient receives and the number of days that support is required, not just the location in which that care is delivered. So a patient who may be in a “critical care unit” but who only receives level 0 or level 1 support would not attract an additional tariff. This will have be the case for many of the patients currently treated in the “HDU” at Grantham.
You are completely correct in saying that commissioners would not continue to pay for the level 2 service in Grantham as the service clearly does not meet the new requirements for that and the additional tariff will only be payable for care delivered in a service that meets those requirements. Commissioning colleagues would I am sure not wish to commission and fund a service on the Grantham site that was “substandard” even if ULHT continued to provide the current level of service on the site.
Commissioners will continue to commission and fund a level 2 and 3 critical care service for Grantham patients, that can be accessed via the Grantham site, but will be provided elsewhere.
In terms of A&E on the site, I would reassure you that discussions around critical care services have occurred only because of the need to review services against the new critical care national requirements. These discussions pre-date by a significant period the current issues/ concerns regarding the A&E service at Grantham and are in no way related to the A&E service or are in any way an attempt to influence the status of the A&E service. The only change that has occurred in A&E in Grantham in 2016 has been related to the opening hours of the service – the type of patients who are seen and managed in the A&E hasn’t changed in anyway.
There is a requirement that A&E services require access to critical care support for the stabilisation of acutely ill patients. For Grantham this is provided by the arrangements described above. We have not made any changes to the staffing or resources that are available on the site to assist in A&E or to undertake stabilisation of acutely ill patients on the site.
The change to HDU/ ACU affects only on-going care not immediate stabilisation or resuscitation and will not affect the very sickest patients on the site who are already being transferred out to receive on going level 3 support, a process which has been in place for over 10 years and has not been changed. And the resources that support that remain in place. There will be a small and less sick group of patients who will now be managed in the same way as those most sick patients to access on going level 2 care. However, as the services currently in place to support patients requiring the highest level of critical care support will remain as they are at present, I personally cannot understand the logic that says that it would not be able to support an A&E going forward.
The level of critical care support that will be required for different emergency care/ A&E/ urgent care centres going forward isn’t, I don’t believe, clear. The concept of A&E centres that would provide a higher level of care than urgent care centres but not all of the on-site specialist care that an emergency centre would has been put forward. These A&E centres would take selected emergency patients which is currently the case for Grantham A&E and would have the ability to undertake resuscitation and stabilisation which Grantham site does, but wouldn’t require an on-site critical care unit.
Grantham site only accepts a limited range of medical emergencies and those patients whose care cannot be met on the site are already being screened out by EMAS or GPs prior to arrival. This of course does not preclude patients being brought into A&E by their carers/family but we are maintaining the services needed to resuscitate / stabilise and if necessary transfer those patients who may arrive in that way. A level 1 / 1 Plus unit would be able to support the continued admission of selected medical emergencies whose care can be delivered on the Grantham site and this change to critical care would not affect this.
If possible for more some serious conditions, it’s better and quicker for patients to go straight to the care they need not to a local hospital first where that care isn’t available. We know from the data that patients who have had cardiac arrests, heart attacks, strokes and major trauma who go directly to the right hospital first time are more likely to survive and that those who do survive have better outcomes. So it is the right thing to do even if for some people it means their journey to that “right” hospital takes longer than it would have taken to get to their “local” hospital.
In terms of networking arrangements, all of ULHT’s critical care units – Grantham HDU included – are active members of the Mid Trent Critical Care Operational Delivery Network and we would intend to continue to involve the ACU in those networking arrangements. There are already formal arrangements for advice and support of the service at Grantham form the critical care consultants at Lincoln that includes telephone advice, on site review at Grantham if needed and retrieval of patients to Lincoln ICU when required. Those arrangements have been in place to support Grantham for over 10 years and are significantly more established, advanced and robust than networking arrangements supporting smaller hospitals elsewhere in the country. We are currently looking into telemedicine and other new technology solutions to enable us to improve and sustain that support.
While those arrangements can and do successfully support the site in resuscitating, stabilising and transferring patients who require higher levels of care, those arrangements supporting anaesthetic consultants on site in Grantham do not and cannot meet the new specifications and requirements needed for the delivery a level 2/3 service providing on going on site critical care in Grantham – hence the requirement to recognise that with the change from HD to ACU.
Even if we were able to deliver a service that meets the current specifications the very small numbers of critically ill patients that are seen on the Grantham site would not be sustainable and would mean such a service could not expect to deliver high quality outcomes (ie the concern that lead to changes in the service as long ago as 2002-3).
While I would emphasise that any changes are not “mine” to make but are in response to accepted national guidance and service requirements, I do believe the changes are in the patient’s best interests. As for the small numbers of patients who require formal and ongoing level 2 critical care support, I believe this will be better provided in larger critical care units, that see and treat far higher numbers of these patients and that are able to meet the requirements for formally commissioned critical care services.
I would be very happy to meet with you personally to discuss these issues and your specific concerns in more depth and to have the opportunity to reassure you that the critical care changes are not about “downgrading” services at Grantham, but are about ensuring patients across ULHT get rapid access to the high quality critical care services they require regardless of where they may first present and to ensure you that our all our critical care services meet the latest recommendations and requirements.
If you feel that it would be useful for you to visit our critical care unit in Lincoln and to be able to compare the differences between a large critical care unit and the service currently available at Grantham and to further understand the high quality sustainable critical care services we are trying to provide for patients from across Lincolnshire, I would be very pleased to invite you to contact me to arrange a mutually convenient time for you to visit.
Dr Adam Wolverson FFICM FRCA
Clinical Director Anaesthesia, Critical Care and Theatres Lincoln County and Grantham District General Hospitals United Lincolnshire Hospital NHS Trust