UK: North Manchester National Health Service Trust struggling to cope
13 September 2016
A report by the Care Quality Commission (CCQ) on the state of one of the leading hospital Trusts in the north-west of England reveals the impact of years of cuts to the National Health Service (NHS).
The Pennine Acute NHS Trust runs one of the largest acute trusts in the UK, covering a population of some 820,000 people. It operates from four main sites including North Manchester General Hospital (NMGH), the Royal Oldham, Fairfield General and Rochdale Infirmary.
The CQC inspection took place between February and March, with concerns raised as to understaffing in a number of departments that broke national guidelines and a lack of staff training. It concluded that the Trust was inadequate.
Concerns were raised as to the length of time patients had to wait in all three emergency departments. CQC inspectors found that levels of understaffing were appalling, putting patients’ safety at high risk.
Serious deficiencies were found in maternity care, with some staff accepting low levels of care as the norm. These problems were mirrored in two separate reports that flagged failures in clinical leadership.
At the time the inspection took place, there were 170 serious maternity and gynecology incidents that had yet to be dealt with. Thirteen of these involved critical injury or death.
Staff shortages on maternity wards were highlighted, including 20 midwife vacancies. The numbers of staff did not meet national benchmark standards due to the reduction of the number of midwives. This resulted in hospitals not always being able to provide one-to-one care for women in labour as is standard practice in midwifery.
Staff shortages led to high levels of stress, and sickness rates, increasing dependence on bank and locum staff.
There were issues raised about the lack of adequate staffing, covering a number of different departments. At North Manchester General Hospital there was only one consultant on staff in the emergency department at the time of the inspection. The department is supposed to have nine consultants. There were only half the staff doctors that were needed and five of the 13 junior doctors required. This led to the accident and emergency (A&E) departments becoming overly dependent on locum staff. Figures from the Trust show the staffing problems in the A&E department at NMGH, with nearly a third of medical staff positions being vacant.
In all three A&E departments there were concerns raised as to the length of time patients were having to wait. Patients are supposed to be seen within four hours and hospitals can be fined £120 for breaching this time limit. Half the serious incidents in the trust between April and October—146—involved waits of 12 hours or more by patients.
Up to six months prior to March 2015, 70 percent of the shifts had been filled by temporary locums. The CQC raised questions as to the lack of performance monitoring of locum staff and their inductions.
An induction process was in place for locum staff. However, at the time of the visit, one of the doctors had not gone through this process. Instead the doctor had to rely on nursing staff to be able to locate key items and equipment.
The scale of the staffing crisis is so great that NMGH’s A&E department has considered diverting ambulances elsewhere at night. The report showed a catalogue of problems, with understaffing high on the list.
The lack of staffing in specific departments makes it impossible for staff to reliably deliver safe and effective services. While pointing to the impact of the staffing shortage, the CQC report recognises that in many areas of care across the trust staff were doing their best under these circumstances and were competent and compassionate.
At NMGH, the CQC found that annual staff appraisals were not being carried out. Appraisals are an intrinsic part of staff development and a method of being able to improve standards in clinical care. As low as 23 percent of staff received annual appraisals, effectively denying most staff the opportunity to meet with line managers to discuss issues such as performance.
Induction procedures were in place that would include the opportunity to develop skills and competencies, yet it was clear that due to manning pressures these plans were not always adhered to so that staff often were forced to take on roles sooner than anticipated.
Numerous incidents reported throughout the Trust, as a result of issues highlighted in the report, have led to compromising patient safety and care. This has been costly to the Trust. In 2014-2015, the Trust had the second highest level of clinical negligence claims cases against it nationally.
As in all trusts there will be cases of medical negligence. This can only be compounded by the conditions under which many employees in the NHS are forced to work on a day to day basis.
As the CQC report notes, such conditions are becoming intolerable. It cited one experienced worker in the women’s and children’s services, that includes maternity and pediatrics, who said the numbers of registered nurses on shift in her department had continually dropped over the last few years—meaning staff do not have time to do their jobs properly. Those that remain are terrified of missing the key details they are trained to look out for, but they are under so much pressure they can’t even stop for a glass of water.
The overall situation with NHS staffing is likely to get a lot worse. In the last fiscal year, Trusts ran up a collective deficit of £2.4 billion—with the Conservative government’s aim to make further significant cuts to budgets.
A report published by the Kings Fund think tank warned that in attempting to balance the books, staffing levels will have to be reduced and waiting time targets relaxed—compromising patient care.
At the same time, there has been a massive growth in the private sector within the NHS due to competitive tendering and outsourcing. This has led to a bonanza for private companies winning lucrative contracts to deliver services. Companies such as Virgin Care and Care UK won contracts in 2014/15 worth more than £3.5 billion, five times greater than the previous year.
By last summer it was reported that three in four NHS hospitals were rated as inadequate. By July this year, a total of 26 Trusts under NHS England had been rated as ‘inadequate’ by CCGs.
The slashing of the NHS’s budget by £15 billion in the last parliament and a projected £22 billion in this one is the central cause of Trust’s being rated as failures. This situation is being utilised in order to justify further health care cuts and closures of hospitals.
To facilitate closures and cuts NHS England has divided England into 44 areas, each of which has to submit cost cutting Sustainability and Transformation Plans (STPs). In July, every hospital trust was sent a letter by Bob Alexander, director of resources at NHS Improvement, the health service’s financial monitoring department. The letter instructed trusts to identify departments, with a deadline of July 31, which could be “re-provided” by other institutions. The submitted plans must include a list of services that are “not clinically and financially sustainable.” A department being “re-provided” is a euphemism for its privatisation.
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