Response to chair of SOS Grantham Hospital

On Tuesday 9 August, ULHT announced a severe shortage of doctors in our three A&Es. There is a national shortage of appropriately trained doctors to work in A&Es and ULHT is seriously affected by this. We don’t have enough doctors to fill shifts in the three departments 24 hours a day, seven days a week.

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Response to chair of SOS Grantham Hospital.

I’d like to thank you for taking the time to write to me representing the views of Grantham people, and bringing these to my attention.

On Tuesday 9 August, ULHT announced a severe shortage of doctors in our three A&Es. There is a national shortage of appropriately trained doctors to work in A&Es and ULHT is seriously affected by this. We don’t have enough doctors to fill shifts in the three departments 24 hours a day, seven days a week.

We are unable to recruit locums, so our consultant doctors have been filling the gaps by doing extra shifts. Our staff are under enormous pressure and the situation is now unsustainable.

To ensure that we run safe services, we looked at a number of options. These included reducing the opening hours of our A&Es. We ruled out reducing the opening hours at Lincoln and Pilgrim as they both take patients with life threatening injuries (they are known as level 1 A&Es) and have a higher number of patients attending A&E and being admitted than Grantham does. Grantham is a level 3 A&E which means treating more minor injuries and illness. So our only safe option was to look at reducing the opening hours at Grantham A&E.

We have tried to recruit in the UK and internationally, we have offered premium rates (above agency cap) to attract agency doctors, and are investing £4 million in urgent care services. Despite this, we reached crisis point.

Our A&E staff were concerned that if we didn’t act, patients would be put at risk if we continued as we are.

After giving affected staff chance to reflect on the plan, on Thursday 11 August we announced that from Wednesday 17 August, Grantham A&E would be open from 9am to 6.30 pm, seven days a week. This is to boost the number of doctors in Lincoln and Pilgrim A&Es.

I know this has been an unpopular decision, and I share the frustrations of Grantham people. This hasn’t been an easy decision to make but it was made to protect patients and maintain safe services.

As well as our middle grade doctors, we have the support of LCHS, LPFT, NHS South West Lincolnshire CCG and East Midlands Ambulance Service (EMAS) in taking this action.

I will now address the concerns you raised in your email dated 16 August.

Grantham people will not be denied access to A&E services. On average, we expect 31 people to need urgent care between the hours of 6.30pm and 9am. Many of these patients will be signposted to alternative local services by NHS 111 such as GP out of hours, or neighbouring urgent care centres or minor injury units. Those who need the expertise of A&E doctors will be signposted to their nearest A&E by NHS 111, this may be Lincoln, Peterborough, Pilgrim or Nottingham. Those who need emergency care are being asked to call 999 and they will be taken by ambulance to the most appropriate A&E for their condition. We expect on average that six people will need to be transported by ambulance, but due to extra services we have put in place jointly with EMAS and LCHS, we expect three of these will be able to be treated by emergency admissions unit at Grantham hospital.

We are working with LCHS, Lincolnshire South West CCG and local GPs to look at options to boost GP services during these hours. We are in the early stages of planning, I will share with you the plans once I have more information.

I think the independent research you write about that shows there’s an increased risk to life for every kilometre travelled is the Nicholl, West, Goodacre, Turner study. This was published in 2007, before regional trauma, cardiac and stroke networks were introduced. Since these networks were introduced in 2012, research shows and is cited by the Trauma Audit and Research Network (2015) that “more people are surviving severe injuries and illness despite often bypassing their local hospital for treatment”.

As you are aware, currently Grantham people with the most life threatening conditions aren’t treated at Grantham hospital. They are taken by ambulance to Lincoln, Pilgrim or Nottingham. If a person who lives on Manthorpe Road in Grantham, for example, has a heart attack at 12pm today when Grantham A&E is open, 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. Survival rates for Lincolnshire patients following a cardiac arrest are better than the national average.

There is no set timescale in which to resuscitate patients. Paramedic staff are highly skilled in resuscitating patients and stabilising them until they get to a doctor at A&E. In the case of heart attacks, the national target from the time that an ambulance is called until the coronary artery is opened by a cardiologist using primary percutaneous coronary intervention is less than 150 minutes. Lincolnshire Heart Centre 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. Patients with multiple traumas following road traffic accidents on the A1 are taken to Queens Medical Centre at Nottingham.

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.

In 2007, the National Stroke Strategy (Department of Health, 2007) said that specialised stroke care units were the single biggest factor that can improve a person’s outcome following a stroke. Following this, services for stroke admissions services are provided at fewer locations, to ensure that the level of service provided is as high as possible. In Lincolnshire, the hyper acute stroke units are at Pilgrim and Lincoln hospitals.

In making our decision to reduce the opening hours of Grantham A&E, we carried out an equality analysis. The different needs of protected groups such as people with disabilities and families have been considered. We have a plan to mitigate any adverse impacts on these groups where possible.

In developing our plans we worked with South West Lincolnshire CCG, local GPs, LCHS and EMAS. EMAS are supportive of our plans, and said they can cope with additional demands on their services. As I explained, this is expected to be on average three patients a day who need to be transported by EMAS to alternative A&Es. They have factored this into their plans.

We haven’t set the threshold to reopen Grantham A&E too high. The numbers of doctors we have said we need are still below recommended levels set by the Royal College of Emergency Medicine. ULHT has for some time been operating at levels which have significantly overstretched the limited workforce, potentially leading to increased stress levels and enormous pressure on our doctors. Our A&E staff were concerned that if we didn’t act, patients would be put at risk if we continued as we are.

We had continued at these levels because of our expectation that staffing levels would improve. We have to be certain that when we do reopen that we are not returning to this unsustainable and vulnerable position and set out to achieve staffing levels that are consistent safely to meet the increasing demand.

The closure of A&E is temporary, so will not destabilise the hospital. Grantham hospital has a positive future and has a key role to play at ULHT. When talking to staff we have been open and honest, and we offer flexible working patterns to keep our staff where possible. Annual turnover of staff at ULHT is low at 2% – which is lower than the same time last year at 2.5% – and is the lowest in the East Midlands. Due to the national shortages in many medical specialities and nursing roles, we are working hard to keep the staff we have.

Unfortunately, the nursery closed at Grantham two years ago. A private provider, not ULHT, ran the nursery. It was closed when the contract ended with the provider, and unfortunately no suitable bids were received as part of tender process to find an alternative provider. We help ULHT staff with children. We offer childcare vouchers to support staff with the cost of paying for Ofsted registered childcare for children from birth to their 16th birthday, nurseries, pre-school, before and after school, and holiday childcare. Lack of childcare support has not featured as a significant reason for leaving in our recent exit interviews.

Due to a severe shortage of doctors, we had to make this difficult reason quickly, so it hasn’t been a perfect process. We didn’t act unilaterally and worked with NHS partners and other stakeholders where possible.

As the closure is temporary and made quickly on the grounds of patient safety, unfortunately we were not able to consult the public. We are committed to involving the public and patients in our long-term plans and decisions, and are fully committed to the LHAC consultation.

Over the next few months, we will be going out talking to ULHT members and community groups about Grantham A&E to understand how this is affecting people.

The GP out of hours service is still in place at Grantham hospital, and is available to people of Grantham via calling NHS 111. As I have already mentioned, we are working as an NHS community to look at other primary care options.

We have worked with the media to raise awareness of the changes to the A&E. This has included all local and regional media, as well as national media to ensure the messages are heard by as many people as possible. This has been supported by social media promotion, leaflets and posters. We are also working with local groups to ensure we reach hard to reach groups in the area.

Directing people to NHS 111 for urgent care, and 999 in an emergency, is the safest advice for patients. This recommended by NHS England as the best advice to give patients. NHS 111 will assess their symptoms and immediately direct them to the best medical care. Unlike with NHS Direct, there is no call back. They immediately assess a patient and direct them to best care.

Regarding your question about whether we will be providing accommodation for people while they wait for an ambulance or taxi, we do not expect many people to have to wait in this way. We hope that good and informative communications, which we hope you will support, will ensure attendances only in opening hours.

We will work hard to recruit more doctors over the next few weeks and months, and continue to offer premium pay to attract doctors to the county. ULHT and the CCG are committed to fully reopening A&E as soon as we have enough doctors. But we won’t compromise on safety to deliver convenient services.

Again, thank you for taking to time to write to me and share your concerns.