With effect from 29th July 2013 the acute Hospital Trust has downgraded A&E services at Cheltenham General Hospital (CGH) between 8pm and 8am. During this period the A&E Department will be staffed by Emergency Nurse Practitioners (ENPs), rather than specialist A&E Consultants and Doctors.
Emergency ambulances will no longer go to the nearest acute hospital between 8pm and 8am, but will go directly to A&E at Gloucestershire Royal Hospital (GRH). “… between 8pm and 8am the Emergency Department at Cheltenham will operate under the title of ‘Emergency Care Centre’ (ECC) with the services equivalent to an MIU [Minor Injuries Unit]. ED [Emergency Department] service will continue unchanged 8am to 8pm.”
“Patients that (sic.) can be conveyed to CGH ECC [Cheltenham General Hospital Emergency Care Centre] by ambulance between 8pm and 8am include:
- Patients who fall within the scope of the Gloucestershire MIU [Minor Injuries Unite] Ambulance Criteria.
- Adult patients in cardiac arrest related to refractory VF or PEA with non-traumatic causes – who are being actively resuscitated and for whom CGH [Cheltenham General Hospital] is the nearest acute centre.”
In other words, overnight, paramedics will have to triage patients to decide whether:
· to treat them on the spot;
· take them to a Minor Injuries Unit (MIU), if they meet the new criteria for MIUs;
if they do, but are assessed by an ENP [Emergency Nurse Practitioner] at the MIU [Minor Injuries Unit] as needing acute care the ambulance will continue to the nearest ED [Emergency Department] (i.e. at night: Gloucester)
· take them to Cheltenham ECC/MIU, if that is the nearest acute centre and they have suffered a cardiac arrest;
· take them to Gloucester, if the patient’s condition does not meet the criteria for an MIU and is any other clinical condition (i.e. non-cardiac arrest);
or take them to Bristol (Frenchay) if it is a major trauma injury.
“GPs will still be able to refer in to Cheltenham during the hours of 8pm and 8am but these patients will be admitted, instead, directly to the Acute Care Unit.” In others words, this by-passes A&E (which is a change to the procedure introduced by the Hospital Trust in 2008/9 under the Utopia project).
The Hospital anticipated that around 16 patients a night would be diverted to GRH, but reported that, in the first month of the new service, “999 patients were directed to A&E at GRH rather than CGH” (source Trust report to Health and Care Overview Scrutiny Committee). If GRH is unable to cope with the number of arrivals at A&E, patients may be redirected to CGH, or to Bristol.
There has already been one report of an ambulance arriving at CGH and being diverted to GRH, only to find A&E there was too busy and being diverted back to CGH! This ambulance was tied up for a total of four hours!
Patients from Cheltenham and parts of Gloucestershire to the North and East of the county, who ambulances would, in the past, have taken to CGH, will now be taken to GRH. Those who are discharged, even in the middle of the night, will be expected to make their own way back to Cheltenham, or wherever they live. The Hospital will call taxis for discharged patients, but the taxi fare from Gloucester to Cheltenham is £20 and even more overnight.
Reconfiguration of A&E (Proposal 1) was part of a public consultation run by the former Primary Care Trust about the reconfiguration of various services at the two hospitals, including: changes to Gastroenterology, Cardiology and Respiratory Medicine (Proposal 2) and closing Paediatric services at CGH and transferring them to GRH (Proposal 3).
The Trust’s explanation for the reconfiguration given in the ‘public engagement’ document:
“Despite numerous attempts, the Trust has not been able to recruit close to the number of recommended doctors in emergency medicine it needs to maintain services the way they are currently set up in the county.”
Specifically, “Since 2009, the Trust has repeatedly tried to recruit to reach the CEM’s recommended minimum number of 10 Emergency Medicine CONSULTANTS per site covering 16 hours/day”.
A report from the College of Emergency Medicine in May suggested that nationally 92% of Consultancy posts were filled, while the Trust had only succeeded in filling 55% of the 20 Consultancy posts required.
Indeed the Board now admits that the establishment for A&E Consultants is only 12/13, not the 20 required to fully staff A&E departments at both hospitals and that they effectively have their ‘full establishment of A&E Consultants’. In other words they had already abandoned the attempt to fully staff both A&E departments before the public consultation.
Since then the Board appears to have subtly shifted its position to emphasise the difficulty it has had recruiting sufficient numbers of ‘middle ranking doctors’.
Wider impact on patients
It is not only residents in Cheltenham who may be affected, roughly one third of the county’s population live nearer to Cheltenham General.
Furthermore, from March to July the total time taken for ambulance diverts between the two sites was falling from a high at the end of the winter of around 3500 minutes (~58hrs) to around 750 minutes (~12.5hrs). In August, following the reconfiguration this appears to have increased ten-fold to around 7500 minutes (~125hrs). This could have a direct effect on ambulance services across the whole county. (Source: Publicly available Board papers for September).
Most of this appears to be made up of patients being transferred from Gloucestershire Royal to Cheltenham General, to free up beds in GRH.
What REACH wants
REACH accepts there is a short-term problem with recruiting A&E Consultants and Doctors across the country and, because of the length of time it takes to train them, this problem will not be resolved quickly. However, we want Gloucestershire Clinical Commissioning Group (GCCG) and the Hospital Trust to commit to restoring fully staffed A&E departments at both hospitals as soon as possible.