For Faith Button, keeping patients flowing through the hospital system is something like a jigsaw.
As the woman in charge of performance at Central Lancashire’s hospitals, she hopes the opening of a new rapid assessment unit at the Royal Preston will be one of the last pieces to fit into place, in order to ensure the picture for patients this winter is better than the last.
And while Faith is braced for the worst the colder weather can bring to an Accident and Emergency department’s doors, she is at least confident that there is now a more appropriate door for patients arriving by ambulance to be brought through.
“We will be able to take people straight in and have a senior team around them immediately,” she explains.
“We will have staff greeting them and making sure nurses take [responsibility for] the patient, so that we can deal with ambulances much quicker and release the crews.”
If that sounds like the way things should always have worked, there is a simple reason why it was sometimes not the case at the Royal Preston - lack of space.
Pictures of patients left in corridors have become the ultimate sign of a health service under strain - but the cramped conditions at the entrance to Preston’s A&E meant a corridor was always the starting point on a patient's journey. And if there was a backlog in the department itself, that was where they had to stay.
“We had no dedicated space, the demand for emergency services had increased and our footprint hadn’t kept up with that,” A&E matron Lynn Sime says.
“Last year was very difficult and patients were being held on corridors, because we had no alternative. So we decided that the extra money we have been given should be spent to ensure patients arriving by ambulance had a much more dignified and slicker experience than last year.”
That extra money totalled £1.9m and was Central Lancashire’s share of a £145m government pot for building works to upgrade ageing facilities.
At the Royal Preston, an area previously used for offices has been gutted to generate space for a new 7-bay unit where the less serious ambulance arrivals will be assessed.
“They will will be met by lead clinicians who will be able to decide [where the patient should go] much earlier in the process,” Lynn explains.
That destination could be the emergency department itself, a ward or an area known as ambulatory care, which deals with any condition where it is expected that the patient should be able to return home the same day.
Meanwhile, the door through which all ambulance patients previously passed will now be reserved for the most seriously ill individuals who can be taken straight to the resuscitation area.
It is hoped that the new arrangement will help further improve ambulance handover times at Lancashire Teaching Hospitals, which have fallen by almost two thirds compared to the same time last year - taking the trust from one of the worst performing in the North West to one of the best.
As well as the new assessment area at the Royal Preston, there is also a dedicated paediatric space and, at Chorley and South Ribble Hospital, a 23-bed ‘winter ward’ has just been opened.
In common with most corners of the NHS, last winter was one of the most challenging on record for the organisation which runs the two hospitals.
Queues of ambulances outside Preston A&E were not uncommon, with more than 10,000 patient drop-offs by ambulance over the winter period last year across the two Central Lancashire sites.
A severe flu outbreak, plummeting temperatures and the winter vomiting bug all conspired to keep hospitals at full stretch and NHS England ordered that all non-urgent operations be cancelled for more than a month.
As she watches the finishing touches being put to the new triage unit on which this year’s winter plan partially depends, Faith Button says the region’s two hospitals are “in much better shape” than this time last year. However, she remains realistic about the challenges that undoubtedly lie ahead.
“Winters are always difficult and we have to face the reality - there will be a lot of admissions and we are now starting to see them creep up,” she says.
“We have been doing lots of continuous improvement work and it’s about all of those pieces coming together to make sure that, as admissions do increase, we can deal with those patients and keep them as safe as possible.”
For matron Lynn, success will be measured by more than the performance statistics on which the NHS is routinely judged - she has her eye to patient satisfaction and staff morale.
“The staff are thrilled - they used to go home from work feeling like they had not done as good a job as they wanted, because they had had to use corridors [for] personal care.
“Now they know they are going to have a dedicated space which is fit for purpose and is going to be so much better to work in. It will also enable them to deliver the kind of care that they want to give.”
TRIAGE CHANGES CREATE SPACE FOR THE SICKEST
A new method of assessing walk-in patients who arrive at Central Lancashire’s A&Es has cleared space for the most seriously ill patients.
Until last month, people had a choice about whether to head for the emergency department at the Royal Preston or the urgent care centre based on the same site.
In recent weeks, they have been triaged and sent to the unit best placed to deal with their condition. The aim is for the privately-run urgent care centre, which also has a facility at Chorley Hospital, to treat the vast majority of minor injuries and illnesses.
“Our urgent care partners are taking about 70 extra patients every day,” Faith Button, Lancashire Teaching Hospitals’ interim director of performance, said.
“That is freeing up A&E for us to treat the sickest patients and enabling our staff to concentrate on them. Urgent care is expanding more and more, with minors patients triaged straight to [the facilities].”
The A&E department at the Royal Preston has doubled the number of ‘majors’ bays fitted with specialist equipment, now that it will be treating fewer minor complaints.
But the most recent board meeting at Lancashire Teaching Hospitals heard that the new process could be having an impact on waiting times while it beds in.
“We knew that the change had elements of risk about it and urgent care have acknowledged that there is variability in their performance,” Adrian Griffiths, chief operating officer, explained.
“But it was absolutely the right thing to do.”
Between October and November, almost 1,500 more patients attended the regon’s so-called ‘type 3’ A&Es, predominantly comprising Preston and Chorley’s urgent care centres. Over the same period, the number of breaches of the four-hour waiting time target more than doubled to almost 600.
However, the figures also include attendances at the main Chorley Hospital A&E, which is classed as a type 3 unit, because it is currently operating only 12 hours per day. Urgent care centre operators 'gtd healthcare' say it would be “misleading” to make any comparison as a result.
David Beckett, 'gtd healthcare' chief executive, said:
“We are really pleased with the success of the minor injuries and minor illnesses streaming at the Royal Preston Hospital and the positive outcomes it has brought for patients.
“We expect the recent completion of the refurbishment works at Royal Preston Hospital to have a positive impact on staff and patient experience and will further enhance overall performance.
“The success of the streaming pilot is enabling our doctors and nurses to see and treat patients in a timely manner; while there has been an increase in type three breaches, this cannot be attributed to the urgent care centre at Preston alone as the national figures incorporate activity at Chorley emergency department and so are slightly misleading.
“Furthermore, we are continuing to work closely with Lancashire Teaching Hospitals colleagues and the Clinical Commissioning Groups to ensure we are supporting the emergency department and delivering services that keep patients safe and receive the best care and treatment.”
FACTS AND STATS
12,490 - number of patients attending Preston and Chorley A&Es/urgent care centres (November 2018)
80.8% - proportion of patients treated within 4 hours of arrival (November 2018)
90% - target for the proportion of patients who should be treated within four hours of arrival.
7 - number of hours ambulances waited at Preston and Chorley A&Es in October, down from 21 hours in April 2018.