| Royal College of Physicians Invited service Review Visit Provision of Services at Bridlington Hospital | |
Background The Hospital Bridlington Hospital is of excellent build and architectural quality but was accepted even at the time of its commissioning in 1987 as having excess capacity for the population of Bridlington. Initially a "community plus" hospital, it joined Scarborough and North East Yorks NHS Trust in 1999. The opinion of all those we interviewed was that this union has never been satisfactorily consolidated. The two main purchasers are Yorkshire, Wolds and Coast PCT, who run directly some of the on-site support services such as physiotherapy, and Scarborough, Whitby and Ryedale PCT. The population served by the hospital is 60,00 in winter rising to 100,000 in summer. Two of the Bridlington electoral wards are in the lowest national quantile for indices of multiple deprivation. The population of neighbouring Scarborough is 86,000 which may rise to 150,000 at the height of the tourist season. A 20 mile coast road joins Scarborough with Bridlington. This if often slow in the summer. (3/4 hour or more by car, 1.1/2 hours by bus) with delays caused by agricultural vehicles and caravans. Bridlington is 50 miles from York and 35 miles from Hull. Bridlington Hospital has 149 acute beds used by Scarborough and North East Yorkshire NHS Trust. These are divided into 4 wards (2 acute wards, 1mainly rehabilitation ward and 1 surgical ward also shared by the physicians). There is a 6 bedded cardiac monitoring unit CCU with one side room often used as a medical high dependency bed. There are facilities for cardioversion and temporary pacing, both of which are carried out on site. In addition there is a GP run palliative care/MacMillan unit and one ward occupied by the Mental Health Trust. One 30 bedded ward is closed having only ever opened for 2 weeks. Approximately 3,500 acute medical patients are admitted per year (average 10 per day). The hospital has a minor injuries unit (MIU) staffed by 3 staff grade doctors during the day and specialist nurses out of hours. There is a consultant cover from Scarborough and one on-site consultant session per week. The MIU is currently closed at night because of temporary difficulties with nurse recruitment. Day case and short stay general, urology and orthopaedic surgery is carried out in Bridlington by consultant surgeons from Scarborough. There is only one theatre in use and consultant anaesthetists cover on 4 lists per week. Medical consultants and junior staff look after post-operative patients. Waiting list initiatives for a variety of surgical procedures are carried out in Bridlington. There is not trauma service, no resident anaesthetic services and no acute surgical service and no intensive therapy unit. There is a small midwife led, maternity unit. It should be noted there is no dedicated day-case unit in Scarborough. Radiological services comprise a 24-hour service for plain films. Barium enema and ultrasound services are provided by visiting consultants who also teach and report plain films. Ct scans are done in Scarborough unless the patient needs neurosurgical services in which case the scan is requested at Hull. On occasions patients have been transported to Scarborough only to be referred back to Hull after their CT scan. There are no on-site pathology facilities. Senior House Officers (SHOs) can use the blood gas analyser for electrolytes, haemoglobin and blood gas estimations. Other samples are sent to Scarborough. There is a very pleasant library and computer, learning facilities and full internet access are all available around the clock. The hospital is very clean, welcoming and friendly and situated in pleasant grounds. There are ample car-parking facilities. There are 4 whole time physicians, 1 with an interest in medicine for the elderly, 1 in chest medicine and 1 in cardiology but the 4th physician (diabetes and endocrinology) is on long term sick leave although there is a locum seconded from Scarborough to cover the on_call. There is funding for 5 staff grade doctors but currently only 3 are in post and there are 5 SHOs all currently in post. The SHOs work a band 3 on-call system. Nursing levels are up to establishment although it was suggested to us that the establishment might be inadequate for needs. There are 3 small GP run community hospitals within the boundaries of Scarborough and North East Yorks NHS Trust at Malton, Driffield and Whitby. (30, 13 and 35 miles from Bridlington respectively) financed separately by PCTs. All host consultant outpatient clinics but are otherwise staffed by GPs. Minor surgery is done at Whitby 35 miles north of Bridlington. Background to Current Visit A number of events had led to loss of confidence in Bridlington Hospital and a loss of morale amongst staff, uncertainties about the future and difficulties in filling middle grade vacancies. The January 2002 CHI report commented on poor inter-personal performance of doctors and expressed concerns about patients safety at Bridlington. In particular weekend surgery, post operative supervision, minor injury referrals, nurse and junior doctors staffing levels and anaesthetic cover were pointed out as areas of concern. Although the report was not specific and did not give details, the issue of risk at Bridlington Hospital was said to "require immediate attention." The report pointed out that the Minor Injuries Unit in Bridlington was misinterpreted as and A&E department not only by local people but also by the ambulance service. It highlighted the difficulties caused by distance and poor public transport in accessing hospital services. It acknowledged that "balancing access, risk and efficiency is acknowledged as difficult and tough decisions are needed to maximise safety whilst minimising the effect on other strongly held principles". General Professional Training (GPT) visits carried out by the Royal College of Physicians have highlighted the professional isolation at Bridlington. Pressure from the College led to the appointment of staff grade doctors in 1996 to provide middle grade support for the SHOs. However an interim GPT visit in August 2002 was still critical of the difficulties the SHOs in Bridlington had in attending the curriculum based teaching in Scarborough, the lack of out patient experience and the difficulties with clinical and educational supervision with the absence of one consultant. There was also concern about the lack of structure to the SHO rotation and the legality under New Deal regulations of running of on call system with 5 SHO's. The Specialist Training Authority (STA) of the Medical Royal Colleges was notified of the situation. As a result of further were not convinced that there had been and improvement in SHO training the posts would lose educational approval. A number of unfortunate clinical incidents have also focused attention on Bridlington. In particular, the death of a patient in Bridlington from a sub arachnoid haemorrhage before a CT scan was carried out and a recent 4 day inquest into a patient dying from a subdural haematoma in Hull following delays in obtaining a CT scan. The Coroner in the last case, while recording a verdict of accidental death, raised the issue of availability of anaesthetic staff for transferring sick patients and whether it was appropriate to admit patients to a hospital without an on-site CT scanner. The Strategic Health Authority is undertaking a review of medical services in the area but we were told is awaiting the College's report on clinical aspects before reporting. Adverse publicity in the press and a need to close the Minor Injuries Unit because of lack of nurse recruitment for a period had led to widespread public anxieties about the future of Bridlington which in turn led to difficulties in recruitment of medical staff and in particular medical staff Grade doctors and a lowering of morale at Bridlington. The CHI report pointed out and we confirmed that there had been a prolonged period when management did not engage with clinicians and there was a lack of strategic direction for the trust as a whole and particularly for Bridlington. On April 1st 2002 a new full time medical director, Dr Ian Holland was appointed and on 2nd September 2002 a new Chief Executive, Alison Guy was appointed. In November 2002 the chief Executive requested the President of the Royal College of Physicians. Professor Carol Black to institute a tripartite visit from the College of Physicians. College of Surgeons and College of General Practitioners "to look at the credibility of clinical services in Bridlington against this background of mistrust within the professions" The visiting team Charles Collins MA ChM FRCS, representing the Royal College of Surgeons Terms of reference To inform the steering group as to the potential for the use of the site at Bridlington Hospital as part of a local health system which includes Malton, Whitby and Driffield Community Hospital linked to the main site in Scarborough. Terms of Reference Item 1: We felt it our main priority to address this issue and discussed it with everyone we interviewed. We concluded that although there are important safety issues at Bridlington, many of the concerns raised could not be substantiated and related to perception and sometimes rumour rather than reality. Representatives from the Yorkshire, Wolds and Coast PCT in particular were very supportive of the quality and safety of service provided by Bridlington Hospital. The recent coroners cases highlighted two particular concerns at Bridlington, firstly the lack of a CT scanner on site and secondly the difficulties in obtaining anaesthetic cover for transfer of patients to the neurosurgical unit at Hull. A CT scanner on site is desirable and should certainly be a medium term objective. However provided clear guidelines exist and adhered to for not admitting patients needing urgent CT scans, and provided good working relationships exist with radiologist in Scarborough and neurosurgical team in Hull, then we did not feel the absence of a CT scanner constituted unsafe medical practice. If it did then all acute hospitals would have to close to admissions whenever their CT scanner was down for half a day. However the lack of anaesthetic cover for transfer does constitute a major safety issue. Anaesthetist for transferring patients are currently provided from Scarborough Hospital which has 2 out of 10 consultant posts unfilled and 2 out of 5 middle grade anaesthetist posts unfilled. Scarborough anaesthetists are very actively involve in finding a way to solve this problem. The department takes an interest in transfer of critically ill patients and Scarborough Hospital runs at "Training for Transfer" course. Any solution must address the safety of transfer of high-risk patients. There are 10 to 12 such transfers a year but we only obtained information about on transfer in the past year where there had been and actual delay which could have affected patient care. There is also no critical care outreach system for identifying high-risk patients on the wards in Bridlington. There is a cardiac arrest team comprising medical staff grade doctors who are Advanced Life Support (ALS) trained, SHO and nurse but no anaesthetist. There are regular ALS training courses at Bridlington and Scarborough. The Chi report mentioned concerns about safety for surgical patients including weekend "waiting list initiative" patients and post-operative supervision. We raised these concerns with all the consultants we saw and elicited two examples of unsatisfactory practice which had affect patients clinical care. Both reflect the current working practice where surgeons only have occasional sessions in Bridlington so have no satisfactory working relationships with the Bridlington based middle grade and consultant medical staff who are responsible for looking after their post-operative patients. This lack of communication is and important safety issue and will need to be addressed in any solution. Concern had been expressed about the cardiac monitoring unit. Our enquiries revealed there had been problems before the cardiac monitoring unit was opened but none since. We found an efficient, well run unit with very enthusiastic staff grade and nursing cover and all facilities for pacing and cardioversion with satellite monitoring facilities. We found no evidence of safety being affected by lack of laboratory of radiology facilities. There are regular laboratory "runs" between Bridlington and Scarborough. There are facilities for blood gas analysis, Haemoglobin and electrolyte measurements on site and plain film radiography is available 24 hours a day. Other test is needed urgently are arranged by telephone and specimens sent by taxi. There is a radiologist in Bridlington available every day to do Doppler and barium studies. Ambulance staff and residents often considered and used the MIU as an Accident and Emergency (A&E) Department. Part of the problem may arise from the different staffing levels over the 24 hours. During the day the MIU is staffed by staff grades from Scarborough and with an A&E consultant from Scarborough undertaking a session a week but out of hours is run by specialist nurses and is currently closed at night. The ambulance station is next door. There is the potential for seriously ill patients to be admitted to Bridlington MIU for assessment when their needs might be better served by immediate transfer to a fully staffed A&E department. It is essential that clear protocols fro admission to the MIU are created and adhered to. We deal with this again under the heading of MIU. Terms of Reference Items 2 and 4: Case mix and options for the use of Bridlington site. We deal with these two interrelated issues together and list below 3 options for the use of Bridlington Hospital with discussion of their advantages and disadvantages and how they would impact on the safety issues listed above. We have expanded on the details of our preferred Option 3. We deal separately with the MIU. Option 1: build on the existing system with no major change to volume or case mix. This option has the advantage that it would require least change. However it has considerable disadvantages. Bridlington would still have underused capacity with the one ward remaining closed despite marked under capacity in the 2 neighbouring hospitals. It would still need extra financing. It would be seen as patching up without and radical change or vision and would be unlikely to inspire the confidence or enthusiasm needed to sustain it. There would be the potential for drifting back to the current status quo and it would not be seen as the secure option which the middle grade staff in particular felt would be needed to retain staff and fill current vacancies. Nor would there be the critical mass of medical staff in Bridlington to ensure long-term compatibility with the European Working Time Directive (EWTD) Option 2 Close all acute medical services in Bridlington and downgrade the hospital to and intermediate care (step-down) and rehabilitation unit. Bay case surgery but not short stay, surgery to continue. Closing acute medicine in Bridlington would also put pressure on all beds in Scarborough and further increase surgical waiting list times there. We were told there would be considerable local opposition if acute services were withdrawn from Bridlington. 17,000 residents had already signed a petition to protest when the MIU had to close temporarily at night because of lack of nurse practitioners. Such local and political pressures would only cause more delay and uncertainty. Staff would leave and would not be able to be replaced. Morale would fall and the local enthusiasm and good will currently still very evident in Bridlington would be difficult to rekindle. Even allowing for sending convalescent patients to Bridlington, Scarborough would still need increased resources to cope with the 30% increase in acute medical workload and there would be increased transport costs for patients and relatives. Rehabilitation facilities would still be needed at Scarborough and so would be duplicated on both sites. Option 3 Build up Bridlington as an enhanced Diagnosis and Treatment Centre (D&TC) There are 5 interrelated strands to this option: medicine, anaesthetics, surgery, obstetrics and education/training. The appointment of extra SHOs will enable the current SHOs to attend out patients more , will enable a change from an on-call system to a partial shift system and enable them to attend teaching at Scarborough rather than use the unsatisfactory tele-link as at present. Our recommendation for surgery is that and enhanced D&TC is established in Bridlington. This would run through the week offering orthopaedic, general and urological surgery. It would bring in surgeons on site every day and a satisfactory relationship could be established between visiting Scarborough surgeons and Bridlington physicians. It would be and enhanced D&TC because of the availability of acute medical services on site to deal with medical complications in surgical patients. It seems unacceptable to us that there is a closed ward and spare capacity in the existing day unit and theatres in Bridlington while Scarborough and Hull have long waiting lists and regular waiting list initiatives purchasing services from private hospitals as far away as Darlington. This surgical expansion would require the development in the existing suite of a second main theatre with down-draft ventilation for orthopaedic and possibly ophthalmic use. There could be 20 lists per week and in addition endoscopy and local anaesthetic lists in the existing minor-ops theatre. Bridlington is a clean modern hospital currently free from MRSA and would be a perfect centre for joint replacement surgery. The working environment for surgeons and staff is ideal. One surgeon who had been working in Scarborough and Bridlington for 15 years commented that it was a "sheer delight to work in Bridlington" The development would require expansion of surgical staff, which would at the same time relieve what is currently an unsustainable emergency rota, particularly in trauma and orthopaedics. It is not feasible to provide a trauma emergency rota with fewer that 6 consultants. There are only 4 orthopaedic surgeons in the trust and two new orthopaedic consultants could contribute significantly to an expanded sustainable elective service in Bridlington as well as creating an acceptable emergency trauma commitment in Scarborough. Currently discussions are under way to appoint one general surgeon based at Scarborough and one in Hull with interests in upper GI surgery, both of whom would have outpatient and operating sessions at Bridlington. These should be progressed. Further appointments in Scarborough would be required to bring the ratio of general surgeons to population towards the target of 1 per 30,000. Other specialities under pressure in Scarborough might wish to use the expanded and better staffed and supported facilities in Bridlington. Furthermore the resources, when fully-developed might be very attractive to Hull based surgeons who we understand are under great bed-pressure. All this would enable further surgery to be carried out at Bridlington. To strengthen the orthopaedic service, consideration should be given to the appointment of an ortho-geriatrician or to one of the existing rheumatologists or Physicians transferring interest to ortho-geriatrics. Most of these increases are needed now to maintain existing services. The main expansion needed for Option 3 would be the department of anaesthetics. The anaesthetists who are already 2 under consultant establishment would need to increase their consultant numbers by 2 from an establishment of 10 to 12. this is still less than the number recommended by the Royal College of Anaesthetists. In addition there would need to be 5 middle grade doctors appointed to cover the Bridlington site. These staff grade doctors would act as Critical Care doctors, would do on-call and would assist with the care of seriously ill patients in Bridlington and be available for patients transfer. Doubts were raised about the ability to appoint these staff grades. Although there was no anaesthetic representative on the visiting team we were led to believe that posts attractive to staff grade anaesthetists could be constructed if there was no requirement for obstetric cover at night. The obstetrics unit at Bridlington is midwife led and its future is currently under separate review. The existing senior medical staff grades in post could also share the rota to provide continuous cover with the anaesthetists with the medical SHOs being first on call as at present. Careful pre operative assessment of surgical patients would be needed by the anaesthetic department to exclude patients likely to need Intensive Care Unit (ITU) facilities post operatively. However the availability of an acute medical team on site would enhance the care of post-operative surgical patients whose safety would be much more assured than those currently transferred to distant private hospitals with limited facilities on site. An influx of surgical patients from outside the Scarborough catchment area would be expected and could impact very positively on the waiting lists within the Strategic Health Authority's borders which stretch from Hull to York and from Harrogate to Tees side. Creating such an enhanced D&TC would also considerably improve the safety and care of medical patients in Bridlington because of the availability of surgeons and anaesthetists on site. Funding has already been agreed for a diagnosis and treatment centre at Goole but we were told this should not be seen as in competition with Bridlington. Goole is 44 miles across country and importantly on the other side of the Humber estuary. The last but perhaps the most important strand underlying the proposed expansion of services on the Bridlington site is the outstanding potential facilities for teaching junior surgical staff and medical students and we deal with this below under Item 3 of the terms of reference. Minor Injuries Unit (MIU) We believe the MIU should stay but with changes. Seventeen thousand cases are seen a year. These patients could not at present be accommodated in Scarborough and closure of this unit was thought unacceptable by all we interviewed. We share the view of local and community representatives that "This is too big a town not to have a MIU" However changes are needed. To assist in the distinction between an MIU and A&E department we suggest that the staff grades are withdrawn from the MIU making it clear that this is a nurse run MIU rather than a mixed doctor led unit during the day and nurse run unit at other times. It is essential that clear protocols are created and adhered to for admissions of patients to the MIU. And deciding which patients should be taken directly to Scarborough. The Ambulance Service, local GP's and community must all be involved and subscribe to these protocols to prevent inappropriate admissions. We looked at the possibility of the MIU remaining closed after 10 pm (as it is at the moment because of lack of staff.) This would help emphasise the limitations of the department and would save money but would downgrade the services normally available to Bridlington residents. GP's could still admit directly to the wards. We also discussed closing the hospital to all admissions after 10pm. However if the current medical staff grade and anaesthetic staff grades were in post this should not be necessary and it would considerably disadvantage medical patients already known to Bridlington Hospital. The recent threat of closure of the MIU led the local GP's to move their out of hours centre out of the MIU and away from the hospital. Relocating it back in the MIU unit should be a priority. The hospital and out of hours centre enhance each other and depending on activity, the on-call GP could be involved in covering night duties in the hospital. Consideration should also be given to the appointment of Critical Care specialist nurses who could also reduce the need for medical night cover. All these alternatives are possible within the context of Option 3. The details of cover and opening times would depend on figures for the case- mix of MIU attendances and ward admissions after 10 pm as well as recruitment opportunities and financial issues. Consideration should also be given to increasing Staffing levels on the MIU in the summer to cope with seasonal influxes of holiday visitors. Terms of Reference Item 3: Future Changes In Training And Education SHOs The European Working Time Directive (ETWD), to be implemented by August 2004, will impose severe strains on all acute medical services not just those in hospitals such as Bridlington and Scarborough. As currently formulated the EWTD will be very difficult to implement without considerable workforce development. A postponement for 3 to 6 years has been sought by the Royal College of Physicians. Because of the uncertainties surrounding the EWTD it is difficult to make any detailed recommendations as to what contingency plans can be put in place now to assist its implementation. However the increased medical staffing under Option 3 will put Bridlington on a stronger footing than at present to contend with the EWTD. Furthermore, a recent Royal College of Physicians commentary stressed the danger that implementation of the EWTD would increase work intensity of trainees to an unacceptable level and emphasised the need to impose limits on the number of patients under the care of a given complement of doctors. Smaller hospitals such as Bridlington Supplied by Mick Pilling (chairman) Save Bridlington Hospital Campaign Action Group "We need NHS and social care staff to get actively involved if we are to achieve this vision. I stress, and my Ministerial colleagues support this, that this is not about imposing change from the centre. For us all to take the NHS forward, and to improve our services, the NHS needs to involve its entire staff better than it has in the past. I agree with what many of you have told me as I've visited NHS and social care teams across the country: effective change should be led by clinicians and should driven by the needs of local communities." Professor Ara Darzi 2001 The following report 2003 of the Royal College is considered important since the SNEY Trust are quoted as saying " The Royal College review was going to be expensive; in discussion with our medical consultants it was not felt that this would be money well spent as the view was that the Royal College would reiterate the 2003 report as it applied to Bridlington “ which we already knew. " You can note that effectively SNEY Trust are following Option 2 which is a down grade of Bridlington Hospital and on page 7 of the report it says of the advantages of this option "The advantage of this proposal is that it would release the 5 SHO's for use in Scarborough. It might also be the cheapest option." Yet the answer appears to be misleading on this fact The Trust also repeatedly refer to the lack of the diagnostic facilities, yet the Royal College report said when giving an informed opinion as to whether the services currently provide at Bridlington are safe. "We concluded that although there are important safety issues at Bridlington, many of the concerns raised could not be substantiated and related to perception and sometimes rumour rather than reality. Representatives from the Yorkshire, Wolds and Coast PCT in particular were very supportive of the quality and safety of service provided by Bridlington Hospital." The Royal College delegation also say: "A CT scanner on site is desirable and should certainly be a medium term objective. However provided clear guidelines exist and adhered to for not admitting patients needing urgent CT scans, and provided good working relationships exist with radiologist in Scarborough and neurosurgical team in Hull, then we did not feel the absence of a CT scanner constituted unsafe medical practice . If it did then all acute hospitals would have to close to admissions whenever their CT scanner was down for half a day." "We found no evidence of safety being affected by lack of laboratory of radiology facilities". They also give many disadvantages to option 2 and explain why it is not their very educated and informed choice. They clearly advocated Option 3 which would mean a real improvement of facilities at Bridlington Hospital, rather than changes which effectively mean the hospital is downgraded. On the subject of the cardiac monitoring unit The Royal College said the following " Concern had been expressed about the cardiac monitoring unit. Our enquiries revealed there had been problems before the cardiac monitoring unit was opened but none since. We found an efficient , well run unit with very enthusiastic staff grade and nursing cover and all facilities for pacing and cardioversion with satellite monitoring facilities." They note the following " There is also no critical care outreach system for identifying high-risk patients on the wards in Bridlington." You may remember that this changed and senior staff from CMU were trained to provide this and it was put in place. Due to staffing cuts this service has ceased to be provided on this site. Please note that some of the disadvantages of Option 2 are safety issues "Those patients who were transferred to Bridlington for intermediate care would be at greater risk than at present if they became ill in Bridlington Hospital, as there would be no cardiac arrest team. Ambulance services and transport services for visitors would need to be considerably increased." This is a clear point made by the Royal College in the 2003 report. Likewise the Royal College forewarned that moral would drop . "Staff would leave and would not be able to be replaced. Morale would fall and the local enthusiasm and good will currently still very evident in Bridlington would be difficult to rekindle." The Royal College report also warns of other problems with Option 2 which will not be pleasing to either Local people or the Government "Closing acute medicine in Bridlington would also put pressure on all beds in Scarborough and further increase surgical waiting list times there." I believe this would be very unacceptable to local people, I would also suspect that since Mr.McInnes has had three posts in the last seven years that we could expect that if he continues to change employment with similar speed that he will have moved on by time the real problems strikes home. I am aware that the Chief executive clearly believes that in recent years advances mean that we need less beds. I believe this to be very erroneous and I also think recent events have shown this, I also think that such thinking is short sighted and doesn't allow for national emergencies. It worries the author personally that if there was some kind of epidemic that running hospitals on minimum staffing with minimum bed availability that NHS trusts would not cope. The Report favoured option 3 which I believe would take a Trust Board which had real vision. This option would mean building rather than cutting and I am not sure that people like that are around. Note the Royal College say of Option 3. "This is our preferred option as there exists such a clear opportunity to expand the hospitals usage and provide much needed elective surgical facilities. It is the option that draws widest support from patients and professionals and is the option that will most enhance the existing medical services. It is also in keeping with the Governments new initiative "Keeping the NHS local – a New Direction of Travel" and would satisfy the Royal College of Physicians recommendations on " the future of Isolated Acute Medical Services" Supplied by Mick Pilling (chairman) Save Bridlington Hospital Campaign Action Group
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