The unannounced visit by officials from the Care Quality Commission (CQC) began on Tuesday afternoon, exactly 24 hours after the emergence of the letter - signed by five senior managers and medics - which described how some experienced staff had been left “crying with frustration and anger” at having to resuscitate patients in waiting areas.
It also referred to occasions in recent months on which waits for a bed for people being admitted to hospital from A&E had exceeded two days.
Although no doubt an unwelcome backdrop to the inspection, the correspondence and the visit were entirely unconnected - with the latter being part of an ongoing, pre-planned assessment of emergency and urgent care services across the whole of Lancashire and South Cumbria.
At a board meeting of Lancashire Teaching Hospitals (LTH) - the trust that runs the Royal Preston - chief executive Kevin McGee said that inspectors had found “no immediate safety concerns” requiring action.
He also told board members that initial feedback from the regulator on the basis of its two-day trip to A&E had acknowledged the efforts being made by frontline workers to do the best they could for patients.
“They commended the work of the staff [and] recognised that our staff are working under incredibly pressurised circumstances - and this is the case nationally.
“They commended their compassion and their passion for the work that they were doing [and] said every member of staff that they spoke to was very supportive, both of their departments and the organisation and the work that we are doing.
“I think it was really commendable feedback from the CQC…[and] something I am really pleased and proud [about],” Mr. McGee added.
In February - the latest month for which published data is available - there were 12,782 attendances across all of LTH’s emergency and urgent facilities - an increase of almost 30 percent compared to a year earlier.
The board meeting on Thursday was told that, in the same month, 7.5 percent of emergency department patients waited longer than 12 hours to the point at which they were either admitted, transferred or discharged.
The national target for that measure is four hours, which was achieved in 76.8 percent of cases - above the national average of 73.3 percent and making LTH the third-best performing acute trust out of 19 in the North West.
However, there were also 199 ambulance handover delays of at least 60 minutes - something which chief operating officer Faith Button attributed to the “extremely high” bed occupancy at the trust, which was running at 96.1 percent in February - against an ideal standard of no more than 85 percent.
Papers presented to the meeting revealed that a range of of measures to speed up the transfer of patients from ambulance crews are currently being trialed - in collaboration with the North West Ambulance Service - including the use of the CT scanning waiting area and other “surge” areas to offload patients, depending on the availability of staff, and deployment of an “ambulance liaison officer”.
Kevin McGee also used the board meeting to make his first detailed public comments on the leaked letter, which had been addressed to him and the LTH executive team.
Signed by clinical director Graham Ellis, matron Tracey Thorn, speciality business manager Rachel Standeven and unit managers Clare Holbourn and Deborah Lealman, the document - revealed by the Health Service Journal - claimed that the emergency department was “the fallback” for other areas of the trust.
While wards and assessment areas had their own criteria which dictated when they were full, A&E “apparently has a never ending elasticity in the eyes of others”, creating a culture in which “all roads lead to [the emergency department]”, the authors of the letter wrote.
Mr. McGee stressed the importance of the letter being seen in “the context” of nationwide pressures on emergency care caused by the numbers of people coming into hospital and the subsequent difficulty in discharging them because of similar stresses within social care.
However, he said that it was “right that we respond and support our staff, because they are magnificent in terms of what they are doing and how they're having to work…[under] the most extreme pressures”.
He said the “remedial work” that had recently been put in place included the use of “virtual wards” to try to reduce the need for some groups of people to come into A&E in the first place, as well as efforts across the health and social care system to create additional capacity. That included space within care homes and the availability of care-at-home packages, along with extra bed capacity in hospital,” Mr. McGee said.
“Our ability to do more, however, is constrained because of staffing,” he warned.
“We can't just keep asking staff to work longer hours [and] it's very difficult to get bank and agency staff. Large numbers of our staff are off sick because they are being affected by Covid as well.”
The hospital boss also said that the solution to the current problems included securing finance in the short-term to create an emergency department that was physically “fit for purpose” - and focusing longer term on the new hospitals programme, which seeks either to partially rebuild the Royal Preston where it stands or construct an entirely new facility on another site by the end of the decade.
“The physicality of our A&E department is very, very poor - it’s small, it's cramped, it’s not fit for purpose,” Mr. McGee added.
WHAT ARE HEALTHCARE INSPECTORS DOING IN LANCASHIRE?
Lancashire and South Cumbria is amongst the first of 11 parts of the country where urgent and emergency care services are being inspected on a regional footprint across multiple NHS organisations.
The Care Quality Commission (CQC) says that it is piloting the new approach in order to “see how services respond to the challenges they face as individual providers, but [also to those] that require a system-wide response” within integrated care system (ICS) areas like Lancashire and South Cumbria.
The regulator says that the broader inspections will help the NHS in a particular patch to “better understand the journey people experience when seeking urgent care [and] identify where they can make improvements”.
Individual providers like Lancashire Teaching Hospitals (LTH) will get their own report with the CQC’s findings about their services, while a summary assessment will be produced for the ICS area as a whole.
LTH chief executive Kevin McGee told board members that it was likely there would be recommended actions to which the trust would need to respond once the system review - which began at the University Hospitals of Morecambe Bay trust last month - was complete, but that this was likely to be several months away.
The last time that LTH received its own individual CQC inspection was in 2019 when it was rated as “requires improvement” for the fourth consecutive time during the 2010s. However, It did achieve a “good” standard in the “caring” and “well-led” categories in that most recent inspection report.