Acute emergency and maternity services

Case for change

Improving the quality and safety of acute emergency – adult and paediatric – and maternity services was identified as one of the NHS in London’s key priorities for 2012/13. Whilst NHS London’s HSMR has consistently been lower than all other SHAs and decreased by 11% from 2005 to 2011 – the largest of any SHA – outcomes are still not as good as could be achieved, and not as patients should expect, particularly at the weekend.

Several recent reports from influential professional bodies, such as the Royal Colleges and NCEPOD  (National Confidential Enquiry into Patient Outcomes and Death) have highlighted deficiencies of care in adult and paediatric acute emergency services. Significant evidence demonstrates a variation in outcomes for patients depending on the time and day of the week that they attend an emergency department, or are admitted to hospital as an emergency.

Additionally, London’s maternity services do not perform uniformly well with unacceptable inequalities in maternity outcomes in areas of mortality, morbidity and experience. This has been explicitly highlighted in several recent reports and reviews including the 2011 London maternal death review , Care Quality Commission (CQC) reports from individual Trusts and the London Local Supervising Authority (LSA) annual report.

These variations in emergency services outcomes have been associated with a lack of immediate access to senior medical personnel in the assessment and management of acutely ill patients; a lack of timely access to diagnostics and consultant reporting; and insufficient input from multidisciplinary teams, particularly outside of traditional normal working hours.

The Quality and Safety Programme was set up to review all hospital-based acute emergency and maternity services.  The programme built on the successful changes to other emergency services across London to improve the care and treatment of patients with major trauma, stroke, heart attack or complex vascular problems, which have delivered significantly improved outcomes for the population.  Examples include:

  • London’s heart attack centres which operate a consultant-delivered service seven days a week see no observed difference in mortality rates in the week and at the weekend – demonstrating that where systems are in place to respond seven days a week, there is a direct effect on mortality rates.
  • As a result of the centralisation of major trauma in to four major trauma centres an additional 58 Londoners who were expected to die of their injuries, survived, in the first year of the London trauma system going live.
  • An estimated 200 lives saved across London and will continue to be saved each year following the centralisation of acute stroke services in eight hyper-acute stroke units.
  • Improving the quality and safety of other acute services to meet defined minimum quality standards will complete this journey.

The programme of work

The Quality and Safety Programme carried out a review of emergency pathways for acute medicine and emergency general surgery patients, which was led by Professor Matt Thompson, Consultant Vascular Surgeon, St Georges Healthcare NHS Trust. The review demonstrated that patients admitted as an emergency at the weekend have a significantly increased risk of dying compared to those admitted on a weekday. This suggests a minimum of 500 lives in London could be saved every year if mortality rates were the same.  Reduced service provision, including fewer consultants working at weekends, is associated with this higher weekend mortality rate.  Consultant presence at the weekend is found to be half of what it is on weekdays across London.

London quality standards were developed to improve these services, which ensure that the assessment and subsequent treatment and care of patients admitted to these services as an emergency will be consultant-led, seven days a week and consistent across all providers of these services. In summer 2012 the standards were fully endorsed by the London Clinical Senate and then commissioned from hospitals from April 2012.

An audit of all acute hospitals took place between May 2012 and January 2013 to ascertain the current status of London hospitals against these quality standards .

In parallel to the audit the development of standards was expanded to include:

  • Emergency departments
  • Critical care
  • Fractured neck of femur (broken hip)
  • Paediatric services (medicine and surgery)
  • Maternity services – labour, birth, and immediate post-natal care

The final London quality standards represent the minimum quality of care patients should expect to receive in every hospital in London.  Compliance with these standards will ensure that the assessment and subsequent care of patients would be consultant-delivered, seven days a week, and consistent across all providers of these services.

For maternity services compliance with standards will ensure that the assessment and subsequent care of women admitted to these services would be consultant-delivered (when not in midwifery-led unit), twenty-four hours a day, seven days a week and consistent across all providers of these services.

The standards are based on clinical evidence, national recommendations and best practice – several recent reports from influential professional bodies, such as the Royal Colleges, the College of Emergency Medicine and the National Confidential Enquiry into Patient Outcome and Death (NCEPOD), which have highlighted deficiencies of care for many years.

The majority of the standards are therefore already national recommendations that many hospitals in London are not yet meeting.

In addition to the development of standards, each service area reviewed as part of the Quality and Safety programme has undertaken an assessment of the additional services upon which they depend in order to provide an effective service. The service dependency framework combines these assessments into a single framework in order to facilitate broader discussion around the implications for service models.

Clinical expert and service user panels

The Quality and Safety Programme was clinically-led by over 90 clinicians forming multi-disciplinary expert panels with representation from general surgery and medicine, emergency medicine, elderly care, radiology, anaesthetics, intensive care, paediatrics, obstetrics, midwifery and nursing, as well as representatives from general practice. Clinical leads for each service area were appointed by Dr Andy Mitchell, Medical Director, NHS London and chair of the programme’s over-arching clinical board. Appointment to clinical expert panels was through a competitive application process to ensure professional and organisational representation as well as geographical representation across London. Service user panels were also appointed and were represented on each clinical expert panel to provide valuable input and ensure that the patient voice was heard throughout the Programme.

The senior responsible officer for the programme was Caroline Taylor , Chief Executive of NHS North Central London, who has worked with the programme team from London Health Programmes and chaired the programmes’ board.

Relevant leads for each workstream and service area are shown below:

  • Adult acute medicine – led by Professor Derek Bell, Professor of Acute Medicine, Chelsea and Westminster NHS Foundation Trust
  • Adult emergency general surgery – led by Mrs Celia Ingham Clark, Associate Medical Director, Whittington Health NHS Trust, Associate Medical Director, NHS Commissioning Board, London office
  • Paediatric emergency medicine – led by Dr Gulamabbas Khakoo, Consultant Paediatrician, The Hillingdon Hospital NHS Foundation Trust
  • Paediatric emergency surgery – led by Mr Simon Eccles, Clinical Director for Paediatrics, Chelsea and Westminster NHS Foundation Trust
  • Critical care – led by Dr John Coakley, Intensive Care Consultant and Medical Director, Homerton University Hospital
  • Emergency departments – led by Dr Andrew Hobart, Emergency Medicine Consultant, South London Healthcare Trust
  • Fractured neck of femur pathway – led by Mr Gavin Marsh, Orthopaedic Consultant, Croydon University Hospital
  • Maternity services – led by Ms Jane Wilson, Consultant Obstetrician and Gynaecologist and Medical Director, Kingston Hospital and Professor Jacqueline Dunkley-Bent, Director of Midwifery and Head of Nursing, Imperial College Healthcare Trust
  • Interventional Radiology – led by Dr Robin Evans, Consultant Radiologist, Croydon Health Services NHS Trust (until July 2012), and; Dr Tarun Sabharwal, Consultant Interventional Radiologist, Guy’s and St Thomas’ NHS Foundation Trust (from July 2012)
  • Quality and Safety Programme Service User Panel Chairs – Trevor Begg and Arthur Brill

Wider engagement has taken place throughout the review during three stakeholder events held throughout 2012, and at a number of presentations to various forums over the past year.