1. Why did you let it get this stage?
We haven’t rested on our laurels. We have tried to recruit in the UK and internationally, and we have offered premium rates to attract agency doctors whilst investing £4 million in urgent care services. Despite this, we have reached crisis point.
We have had shortages for months. The risk to patient safety has been managed daily. We have extended shifts, used ULHT staff out of hours and backfilled core hours and used medical and surgical middle grades in A&Es. We have also utilised consultant nurses and emergency nurse practitioners where possible to provide additional support and stretching out of hours support into core hours where possible. Consultants have also been working additional shifts and stepping down into the middle grade role. These have not always been possible to consistently apply, nor are they sustainable.
We have asked doctors and nurses working in the community or GP practices to work additional shifts.
Along with many other places were are trying to develop advance nurse practitioners (ANPs) with a MSc level education who can see many of the patients that middle grade doctors traditionally would have seen.
The University of Lincoln has been very supportive and we have two ANPs who have just finished their MScs. This is excellent but it will take several more years before they can work independently to the level of a middle grade doctor.
2. What have you been doing to recruit?
We have a rolling advert for emergency care doctors and we interview all suitable candidates. At Pilgrim, we have four international doctors going through the various stages of a recruitment process. The process takes time particularly with international doctors as they have to pass International English Language Testing System (IELTS) exams to prove their proficiency in English.
We have paid premium hourly rates to attract agency doctors. Since 1 April, 1,582 shifts have breached the agency price cap across our A&Es – this means we have paid higher rates than the government allows to attract staff to cover shifts. During June, July and into August we are seeing a reduction in the availability of agency doctors at a time where we have become increasingly dependent upon locum support.
3. When will A&E fully reopen?
The System Resilience Group (SRG) will review the situation in three months’ time. The SRG is a collection of senior people from the four clinical commissioning groups, Lincolnshire County Council, providers (such as ULHT, LCHS, LPFT, EMAS) and regulators (such as NHS England and NHS Improvement). They will provide important advice and a recommendation whether to open or not.
If it is not possible to reinstate 24/7 services to Grantham A&E after this time, it will be reviewed again monthly.
4. What will happen after three months if you can’t recruit?
If it is not possible to reinstate 24/7 services to Grantham A&E after three months, it will be reviewed again monthly.
5. Why is Grantham losing its service to help Lincoln and Pilgrim?
In order to concentrate our limited medical resource and support our busiest departments at Lincoln and Pilgrim we have had to reduce the opening hours at Grantham A&E. Reducing the opening hours at Grantham means we can move the medical staff to where they are most needed and continue to provide safe patient care across the three sites.
Grantham people with more serious conditions are taken by ambulance to neighbouring A&Es.
Doctors on shift out of hours at Grantham are currently underused. Between 6:30pm and 9am Grantham receives on average 31 attendances. Of these, 25 self-present and six arrive by ambulance. Average 11 patients between 11pm and 7am.
Based on the postcode of those who self-present, the next nearest A&Es are:
Lincoln 50% (14)
Pilgrim 25% (7)
Peterborough 8% (2)
Others 17% (5)
Of course, some of these patients may access alternatives to A&E such as GP, GP out of hours, urgent care centre, or a local pharmacy, or wait until the following day.
Looking at the postcodes of patients bought in by ambulance, their next nearest A&E would be:
Lincoln 50% (3)
Nottingham 25% (2)
Leicester 25% (2)
6. Can Lincoln and Pilgrim cope with the extra patients?
We don’t predict many patients will attend the other A&Es. Between 6:30pm and 9am Grantham receives on average 31 attendances. Of these, 25 self-present and six arrive by ambulance. Average 11 patients between 11pm and 7am.
Based on the postcode of those who self-present, the next nearest A&Es are:
Lincoln 50% (14)
Pilgrim 25% (7)
Peterborough 8% (2)
Others 17% (5)
Of course, some of these patients may access alternatives to A&E such as a GP, GP out of hours, urgent care centre, or a local pharmacy, or wait until the following day.
Looking at the postcodes of patients bought in by ambulance, their next nearest A&E would be:
Lincoln 50% (3)
Nottingham 25% (2)
Leicester 25% (2)
On average we expect, between 6.30pm and 9am, 25 patients to attend alternative services. Most of these will be discharged back to their GP with little or no treatment required. We also expect that three patients will need to be transferred to alternative A&Es by ambulance.
7. Why doesn’t Grantham A&E currently accept the type of patients Lincoln and Pilgrim does?
The infrastructure at Grantham only allows its A&E department to be able to deal with a very limited range of conditions. The hospital isn’t busy enough, and doesn’t have a “critical mass” of patients to have a broader range of services. Emergency and specialist services need to see a minimum number of patients to have the right skills to treat patients. They need to see those types of patients on a regular basis – so it’s like a Formula One pit stop. The more they practice, the better the results. Grantham is a small hospital which services a small catchment population, and the hospital reflects this.
8. Did you consult with EMAS?
Yes we have met and discussed the issue with them over the last few days. They are supportive of our plans.
9. Can EMAS cope with the extra demands on their services?
Yes. On average we predict only three patients will need to be transferred by ambulance to alternative A&Es.
10. How will Lincoln and Pilgrim benefit?
Doctors from Grantham will be moved to Lincoln and to Pilgrim, on a shift by shift basis to where they are most needed. Both A&Es will remain 24 hours, seven days a week and see full range of patients (apart from major trauma).
11. You say this is about patient safety, but isn’t it really about saving money?
No it’s about putting patients first, and not putting them at risk. We won’t save money by changing the opening hours at Grantham.
12. If this decision has been made due to safety, are you saying services are unsafe now?
No. Services are unsustainable they are not unsafe yet. They are at risk of falling over soon. If we don’t act quickly, they will become unsafe and we will put patients at risk.
13. Aren’t you putting Grantham patients at risk as they will have to travel further with life threatening conditions to receive care?
No. Currently Grantham people with life threatening conditions aren’t treated at Grantham. They are taken by ambulance to Lincoln, Pilgrim or Nottingham. If a person who lives on Manthorpe Road has a heart attack today, the ambulance will take them straight to the Lincolnshire Heart Centre in Lincoln. And because of this they are more likely to survive than if they were taken to Grantham. This will continue.
On average we expect, between 6.30pm and 9am, 25 patients to attend alternative services. Most of these will be discharged back to their GP with little or no treatment required. We also expect that three patients will need to be transferred to alternative A&Es by ambulance.
14. Why is it so difficult to recruit doctors to Lincolnshire?
There’s a national shortage of doctors, so all areas will struggle to recruit.
Historically Lincolnshire has struggled to attract people to work in the county including schools, social workers and private industry. The NHS is no exception, and emergency medicine is challenged most of all.
We don’t run big teaching hospitals. Many big teaching hospitals at the centre of speciality training rotations, such as Queens Medical Centre, Nottingham and Leicester Royal Infirmary are relatively protected from the shortages, as they can keep the speciality trainees (‘registrars’) working with them for most of their rotations.
So, over the last few years Lincoln has had one trainee, or none at all, instead of the two that we’re supposed to have.
A few years ago we tried to get registrars at Pilgrim, without any success, as the training programmes didn’t have the funding to increase the numbers of A&E trainees, so currently they have none at all. This is a particularly challenging issue for ULHT as we are the largest acute trust that doesn’t have its own medical school. A high proportion of medical students continue to live and work where they trained, which would benefit the full range of specialities.
The main group of people who apply for A&E middle grade posts outside a speciality training post are overseas graduates. Recruiting from the EU is an option but getting visas for non-EU doctors is extremely difficult and time consuming. Many of these will leave and get onto a speciality training programme as soon as they can, as they can earn more money as a GP or a consultant than they can as an specialty and associate specialist (SAS) doctor. Many other overseas doctors also leave and join locum agencies where they can earn a lot more money.
It’s stressful and antisocial working in A&E, compared to other specialities, and many people are put off for these reasons.
15. Have you been affected by a reduction in the number of junior doctors?
No the problems are with what we call middle grades, and to a lesser extent consultants.
However, the shortage of doctors means they are overstretched and have less time to provide training and support to junior doctors.
16. Isn’t this really about downgrading the A&E through the backdoor?
No, the changes are temporary, and the decision has not been made lightly. We will put patients at risk if we continue as we are. To ensure that we run safe services, we have looked at a number of options and the safest one means that we have had to make temporary changes to the opening hours of Grantham A&E.
We are committed to involving the public and patients in our plans and decisions, and are fully committed to the LHAC consultation.
17. Where should patients go if they need treatment if A&E isn’t open?
Many illnesses can be better treated by people visiting their local pharmacy, calling 111, visiting a GP, GP out of hours services, or attending a walk in centre or a minor injuries unit. During the hours of 6.30pm and 9am, if you are concerned and need medical advice please contact NHS 111, or in real emergency please call 999.
18. What will happen in an emergency if a patient needs A&E?
If you are concerned and need medical advice, please contact 111 for urgent care or 999 in an emergency.
19. How many patients have been taken to other hospitals in an emergency whilst Grantham has been closed overnight and is this considered safe?
As you are aware, Grantham people with the most life threatening conditions are already taken by ambulance to Lincoln, Pilgrim or Nottingham. Paramedic staff are highly skilled in their decision making, provision of immediate treatment where clinically appropriate and where required resuscitating patients until they get to an appropriate place for further care.
In making the very difficult decision, we discussed the potential impact on EMAS with their senior team. The impact across a range of measures, based upon ULHT data, has been lower than we expected.
On average, based upon ULHT information, two more people are being taken to Lincoln County Hospital from a Grantham postcode via 999 ambulance each evening, than before the changes came into effect.
20. Will the ambulance service receive additional funding as its operatives are naturally going to be deployed for longer as they will have to travel further, and by how much and, will they be able to meet the “door to needle time” in the event of a stroke and cardiac emergencies?
ULHT doesn’t fund or commission ambulance services. EMAS is commissioned by Hardwick CCG and is a question for them to consider.
The agreed protocol between ULHT, EMAS and GP is patients with suspected acute strokes or cardiac emergencies are taken by ambulance to Lincoln (for hearts and strokes) and Pilgrim (for strokes). 999 and EMAS prioritise patients based on greatest need to ensure those with serious or life threatening conditions are seen first.
In the case of heart attacks, the national target from the time that an ambulance is called until support by a cardiologist using primary percutaneous coronary intervention is less than 150 minutes. Lincolnshire Heart Centre not only meets this target but performs better than the national average against this target.
For some time, patients with suspected strokes, acutely unwell children, and people who need emergency surgery have been taken by ambulance to Lincoln and Pilgrim A&Es, and they have better outcomes.
In Lincoln and Pilgrim A&E, staff maintain the expert skill levels required to treat these patients. The injured and ill are treated by the right clinicians, in the right hospitals, as quickly as possible. These patients receive more rapid care from staff who can identify life-threatening injuries and illness much quicker, access key tests such as CT scans faster and perform life-saving operations and give life-saving treatments earlier
21. Can the A&E departments to which patients are being sent cope with this extra pressure given that ULHT cannot meet its A&E waiting times?
Before its closure, between 6:30pm and 9am Grantham received on average 31 attendances. Of these, 25 self-presented and six arrived by ambulance.
So far early indications suggest that the expected impact on demand and waiting times in Lincoln and Pilgrim A&Es has been lower than expected. Lincoln are admitting 1 more patient from a Grantham postcode a day and 4 more people from Grantham postcode are going to Lincoln over a 24 hour period of which 2 are arriving by ambulance
However, it has had a positive impact on being able to staff rotas, with 1 in 6 rotas at Lincoln now being staffed by Grantham middle grades.
22. Has account been taken of laying on additional patient transport for Grantham patients when they’re discharged from hospital?
Over the next few months, ULHT will be going out talking to ULHT members and community groups about Grantham A&E to understand how the changes may be adversely affecting patients. We will be discussing our findings with local commissioners to reduce impacts where possible.
23. How are you monitoring that lives have not been lost due to the fact that patients are being transported to Lincoln or elsewhere instead of Grantham?
We are working closely with EMAS to understand the impact the change of opening hours is having on them, their staff and patients.
24. You hold locality forums which are attended on average by a dozen or so members of the public. These according to your website are designed to listen to the public who have an interest in shaping how NHS services are developed locally. With this in mind, do you not think that 19,000 residents who have signed a petition to ask for A&E to be reopened and 7,000 online comments are a clear message that the board have got it wrong by closing A&E overnight?
It wasn’t an easy decision to reduce the opening hours of Grantham A&E but it was the right decision to protect patients and maintain safe services across Lincolnshire. ULHT is committed to fully reopening A&E as soon as we have enough doctors but we cannot compromise on safety to deliver convenient services.
Everyone has a voice. We want to hear from as many people as possible. The NHS belongs to all of use, and we encourage as many people to join the ULHT membership scheme as possible.
Our quarterly locality forum meetings, held across Lincolnshire, provide an opportunity to members of the public to take part in consultation and engagement in developing services from the patient perspective. Details about these forums can be found here Establishment of Locality Forums.
25. Grantham hospital sign states that it is an A&E. Before this closure it was led by a consultant 24/7 so why does the board persist in calling it is level 3 when it is clearly level 1. Do you not need to consult if you change its status?
Before its closure, Grantham A&E wasn’t staffed by consultants 24/7. ULHT employs two consultants in the A&E at Grantham, both of whom are locums and not permanent members of staff. Their working hours were and remain 9am to 5pm Monday to Friday. Outside of these hours, there is off-site on call only.
According to NHS England definitions, Grantham A&E is a level 3 A&E and not a level 1. (see https://www.england.nhs.uk/statistics/wp-content/uploads/sites/2/2013/03/AE-Attendances-Emergency-Definitions-v2.0-Final.pdf)
NHS England’s definition of a level 1, which demonstrates that this does not apply to Grantham A&E is as follows:
“Type 1 A&E department = A consultant led 24 hour service with full resuscitation facilities and designated accommodation for the reception of accident and emergency patients”.
NHS England’s definition of a level 3 A&E is as follows:
“Type 3 A&E department / Type 4 A&E department / Urgent Care Centre =
Other type of A&E/minor injury units (MIUs)/Walk in Centres (WiCs)/Urgent Care Centre, primarily designed for the receiving of accident and emergency patients. A type 3 department may be doctor led or nurse led. It may be co-located with a major A&E or sited in the community. A defining characteristic of a service qualifying as a type 3 department is that it treats at least minor injuries and illnesses (sprains for example) and can be routinely accessed without appointment. An appointment based service (for example an outpatient clinic) or one mainly or entirely accessed via telephone or other referral (for example most out of hours services), or a dedicated primary care service (such as GP practice or GP-led health centre) is not a type 3 A&E service even though it may treat a number of patients with minor illness or injury”.
26. In 2015/16 there were 4,500 999 ambulance admissions at Grantham, how are you coping with the increased transport to other hospitals?
See answer above for question 19.
27. Residents complain it takes 4 weeks to see their local GP, so how can you say that patients should not attend A&E when clearly they need emergency treatment as nothing else is available locally?
If people do need to see a GP urgently between the hours of 6.30pm and 9am, GP out of hours service is available on the site of Grantham hospital. It is by appointment only via calling NHS 111.
Although waits to see a GP in hours can often be longer than ideal, A&Es aren’t the best place to treat ongoing or chronic conditions. For example as A&E doctors don’t have access to a patient’s GP medical record, this doesn’t help support these types of conditions. A&E staff are highly trained and experienced in treating emergency, or acute, or very serious conditions, not routine coughs and colds.
28. How many patients in 2015/16 attended and were admitted to Grantham’s HDU with non-invasive ventilatory support and how many had sepsis?
Between 1 April 2015 and 31 March 2016, 54 patients were admitted to Grantham’s HDU with non-invasive ventilator support and 61 were admitted with sepsis.
29. The Prince of William of Gloucester Barracks state that soldiers are having to be taken elsewhere for treatment after suffering injuries whilst training due to the closure of A&E. This is time consuming and costly for our armed forces who like local residents need care and attention immediately when they are injured or fall ill and deserve to be seen locally.
We have been in touch with the regimental adjutant at the barracks. They told us the impact so far has been minimal and that the two personnel who have been injured have been treated at near-by urgent care centre in Newark. As you may be aware, this facility is expected to close within the next two years.