IJB urged to prevent another Mid Staffordshire Scandal in open letter

Prevent another Mid Staffordshire Scandal – it’s up to you

I am writing to you and also Mr Paul Hawkins, Chief Executive NHS Fife, the Rt. Hon Tricia Marwick, Chair NHS Fife and others, to highlight the immediate danger posed by NHS Fife’s decision to implement contingency plans in Fife and the long term danger posed by the proposal to close St Andrews Out of Hours Service, as part of the government’s redesign out of hours services.

NHS Fife and Fife Health & Social Care Partnership took a decision on 9th April 2018 to introduce contingency measures to the Out of Hours Service in Fife. – Between midnight and 8 am Primary Care Emergency Services are now only available at Victoria Hospital, Kirkcaldy. This means there is one Out of Hours base to give cover of an area of circa 511 square miles with a population of 371,410.

As part of the contingency plans the Out of Hours Service in North East Fife between midnight and 8am was closed.

The present weekday situation in North East Fife after 11pm is there are two ambulances covering the area – one based in Cupar. On a Saturday night there are three ambulances from 8pm 6.30am. Two ambulances must attend a cardiac arrest – a parlous state of affairs if there is no locally based doctor to call on should another emergency arise.

The doctor covering the whole of NEF from central Fife is reported to be “run ragged”. This is unsafe.… (See under Staffing below)

“Getting around (North East Fife) is an area that is identified as being need of relative improvement …. “¹

“In North East Fife 24,039 (33%) individuals live in areas classed as access deprived. This compares to a figure of 18% in Fife as a whole.…”²

The European Agricultural Fund for Rural Development Europe Investing in Rural Areas – United Kingdom – Rural Development Programme (Regional) – Scotland Last modification date 22/2/18 states:-

“ …. In the Scottish Household Survey, adults who live in rural areas are less likely to say local services would be convenient to access than those in small towns and urban areas. Drive times to services are a useful measure to illustrate the population’s access to services. Information available from the SIMD shows the population in “accessible rural” and “remote rural” areas need to travel for longer periods of time to access key services than the population in the “Rest of Scotland…..” ³

“Deaths resulting from accidents account for a substantial proportion of all deaths and are the fourth largest single cause of death in Scotland. Health Boards in rural areas would appear to have higher SMRs (SMR: hold large datasets of historic environment information) than urban ones. In part this reflects increased travelling by residents of rural areas, and delays in receiving emergency medical care after crashes. There was a 52% correlation between the log of population density and motor vehicle death rates. Seven Local Government Districts had SMRs for motor vehicle accidents which were significantly higher than predicted. ..”⁴

At some point in the past, NHF Fife and FHSCP choose to deflect all emergency calls away from GPs and to put out advice through their emergency call website also stating “Sick children should always be brought to the centres – transporting a child with a high temperature does not harm them “If NHS Fife and FHSCP are continuing with these policies there can be no doubt harm will be caused to patients and their families.

The policy of deflecting emergency calls away from GPs can have serious consequences for patients and for the Accident & Emergency waiting times and admissions to hospitals. Researchers at Cambridge University “found that if a GP had checked call handlers’ decisions to send patients to the emergency department, nearly three-quarters of patients would have been advised to do something else – most commonly to attend a GP out-of-hours centre for a face-to-face consultation with a GP or a nurse…”⁵.

In 2011 “…..- Man arrived at St Andrews with severe chest pain had been appointed to attend Glenrothes. CPR performed unsuccessfully”. The man died in St Andrews out of hours centre⁶.

Had this man been assessed by a GP when he was given the appointment to attend Glenrothes the likelihood is he would have been treated as an emergency and an ambulance dispatched immediately.

It can be very harmful to take a child being treated for cancer, whose immune system is depressed to a place where they may well be exposed to viruses and resistant bacteria which can cause illnesses their body cannot fight. Children with cystic fibrosis who develop a temperature, Children with upper respiratory disease etc. are all at risk of harm. Children with even hand foot and mouth disease and/or secondary to another infection can spread the disease which can be much worse in adults, especially if immunocompromised and dangerous to pregnant women. If a child with chickenpox visits a centre and comes in contact with a pregnant woman she and her baby may be harmed. In the worst case scenario the mother may develop hepatitis, encephalitis and or pneumonia. New born babies who catch chicken pox can become dangerously ill. For children with a temperature where the diagnosis is unclear particularly in North East Fife any delay waiting for an ambulance transfer added to the journey time by road will pose an extra risk. It is better to assess children in their own homes in a family setting rather than submit them and their family to a 40/60 minute journey – with the same for return home, when they are already distressed.

The major disadvantage of getting patients to attend Kirkcaldy is in the resultant delay in assessment and diagnosis. This delay can increase the risk for the patient who would have benefitted from earlier intervention –say Meningococcal septicaemia where IV antibiotics can be lifesaving or for those who may find themselves in an acute setting that is inappropriate to their needs. Travelling over country roads, possibly on a cold night in winter, poses its own risks and ads to the distress of those who historically have been adequately managed at home. This new approach can result in needless admissions because the journey to Kirkcaldy can tire the patient or exacerbate their condition making them unfit to make the return journey. The biological and chemical workings of the upper respiratory track when exposed to extremes of temperature can cause nasal congestion and stuffiness. In children with sensitive airways or asthma, the release of histamine when cold air reaches the lungs can exacerbate their condition and possibly trigger an asthma attack. Time is a crucial element when considering many conditions and diseases that require medical attention.

“After controlling for confounding factors, there was a significant tendency for asthma mortality to increase with travel time to hospital, with a relative risk of 1.07 for each 10-minute increase in journey time (P = 0.04). There was no consistent trend for mortality to increase with travel time to general practitioner surgeries. The results of this study support the conclusions of earlier work that inaccessibility of acute hospital services may increase the risk of asthma mortality. The provision of good access to these facilities may be one factor in reducing the burden of avoidable deaths from asthma”⁷

The relationship between distance to hospital and patient mortality in emergencies: an observational study increased journey distance to hospital appears to be associated with increased risk of mortality. Our data suggest that a 10-km increase in straight-line distance is associated with around a 1% absolute increase in mortality⁸

Urgent care Joining UP Care proposals

As part of the governments Urgent Care Joining UP Care proposals, NHS Fife and FHSCP carried out a consultation process between June and October 2018. Imbedded in their recommended options was the closure of St Andrews Out of Hours Service even though, according to Mr Kellet, Director of Fife Health &Social Care Partnership “The process undertaken to assess the options did not discuss ‘closure’ rather the clinical model required for the future and then the locations options stemming from this…” According to the Consultation Summary the purpose of the reconfiguration of the Out of Hours Service in Fife is primarily to achieve viability and sustainability of the service.

Yet, at the time of the consultation NHS Fife and FHSCP did not have sufficient knowledge to inform the concept they were proposing to enable them to make any recommendations. There was no attempt to comply with their Public Sector Equality Duty and carry out a full equality assessment. There was no attempt to identify the adverse effects the proposed closure of St Andrews Out of Hours Service on its rural community that contain a high number of elderly – expected to increase. There was no attempt to carry out the reviews previously carried out in 2011, when the proposal to close Glenrothes Out of Hours service was recommended⁹

There was no consideration given to farmers of NEF who often work well into the night sometimes all night during Spring and Autumn as they prepare, sow and harvest their crops.

“The high rate of deaths in the farming sector underlines the industry’s poor record of managing risks. Every year, too many people are needlessly killed and injured on farms in Scotland”¹⁰

The farmers and their workers, many from abroad had access to a Minor Injuries Centre in St Andrews with access to a GP. Now they are required to travel almost an hour to get the same care. The result is that many will put off seeking help due to the time it would take from their work to seek help.

According to Mr Kellet¹¹ planning was undertaken using a criteria that in itself demonstrates the rural nature of NEF and the need for out of hour’s services within the area. Yet it is used instead to justify closure of the St Andrews Out of Hours Service.

“Planning is therefore undertaken with awareness of:-

• the relative rural access difficulties.
• the access deprivation faced by both North East and West Fife localities.
• the current proportion of the population over 75 in North East Fife.
• the projected increase of the population aged over 75 in North East Fife.
• the relatively high life expectancy of North East Fife.
• the relatively low prevalence of long term conditions in North East Fife.
• the relatively low rate of emergency and potentially avoidable hospital admissions from North East Fife”

“It cannot be assumed that health and social care needs amongst older rural people are or will be evident. Research for Defra in 2013 “identified evidence of significant unmet needs from health services but found that these were often hidden. Service users themselves tend not to identify unmet need, and are also reluctant to discuss challenges around getting the health care that they require. Also, many older rural residents do not seek out preventative health care or even acute treatment, and in some cases avoid seeking care even in moments of emergency and health crisis. Amongst the reasons given for this are a ‘make do’ attitude, reluctance to make a fuss and the explicit and implicit fear of emerging age-related health issues… Research on ageing in rural areas identified a tendency for older people to present to health services in moments of crisis resulting in significant challenges to health service providers and often necessitating “more intensive, immediate, invasive and complex responses”¹²

Queen’s University, Belfast, carried out research into “General practice out-of-hours service, variations in use and equality in access to a doctor” – the aim of the study was to examine geographical variation in the rates of out-of-hours calls and to see if there is any systematic variation in how the co-operative that covers the area responds to calls.

With 230 GPs and a population of almost 400 000 patients this is one of the larger co-operatives in the UK……There is evidence to show that, other things being equal, the willingness of patients to seek care declines with distance. Patients in rural districts tend to consult less than those in urban areas and this holds for serious as well as for minor conditions.

In this study, indicators of health and, by inference, the need for health services, were not associated with distance; therefore a greater proportion of less frequent calls from those further away should have been appropriate. Yet these patients were least likely to have a face-to-face consultation with the GP. Between 23% and 29% of out-of-hours calls have been deemed unnecessary from a medical viewpoint in the past decade and this may represent a rising trend when set against earlier studies…If populations living closer are receiving optimum levels of care then those further away are disadvantaged.

The system might be therefore be modified as in Denmark…to include a financial incentive for GPs to do more home visits to patients who are further away. Alternatively, if the latter are receiving adequate care then local residents are receiving a disproportionate amount of care. If the health of more distantly sited patients was being significantly compromised then perhaps higher levels of usage of emergency services, such as ambulance calls or admissions to accident and emergency units, would be expected in these areas.

McKee,…who looked at A&E attenders to a district general hospital within this Health Board in 1989, showed that there was a strong inverse relationship between proximity to the A&E services and their use. It is likely that the use of alternate services accentuates rather than attenuates the distance effects on the utilisation of out-of-hours services.” ..”¹³

Staffing

The Consultation document (pages 20 and 21) suggests that either of the proposed recommended options would result in between 18% and 29% reduction in unneeded appointments, 9% more home visits at weekends, evenings and public holidays and 12% more advice calls at weekends, evenings and public holidays and between 200% and 300% more home visits overnight! All this while cutting staff!

At the time of the Report to the Board on 27th August 2013¹⁴ “on average, 16 staff on duty across the four PCES primary care centres at evenings and weekends, 10 overnight. These are GPs, Urgent Care Practitioners and receptionists.” The new plan proposes “Weekday overnight: Four clinicians, with the goal being a minimum level of two GPs and two of band six UCPs, with Specialist Paramedic Practitioners supporting these levels as required. Saturday & Sundays overnight: Five clinicians, with the goal being a minimum level of three GPs and two band six UCPS, with Specialist Paramedic Practitioners supporting these levels.”¹⁵ Quite extraordinary!

The St Andrews Out of Hours Service ensures that the best practice in urgent care is provided and meets the local need for the patients of North East Fife. The consistent excellence of the results of the Out of Hours Service in North East Fife, speak for themselves.

It provides care services that meet a need for healthcare that cannot wait until the GP practices are open. It reduces avoidable admissions to Accident & Emergency and hospital admissions.

Having a local service staffed by local people who are used to working together enables the service to benefit from local knowledge to provide a better service for patients.

It offers face to face consultations and home visits – the best service for this rural community.

The Out of Hours Service has highly skilled staff including two GPs until 12midnight and one GP from 12midnight until 8am. This may be considered expensive but the GP’s cover an area half the size of Fife with a population of 57,000-much higher in the summer months. The use of a GP as a senior decision maker reduces the time to assessment and diagnosis, and avoids the need to extend the consultation by having to refer on to a GP by a less qualified person.

“St Andrews Out of Hours Service is located in a purpose designed and built area of the new hospital at the front door, co-located with immediate access to Minor Injury services. PCES has sole use of this area. There is adequate storage and consulting space. There are 5014 attendances per year. GPs and UCPs are available to see patients. MIU and PCES work jointly The MIU is staffed by a UCP with minor injury training, and cover for the MIU provided by the GP overnight”¹⁶

St Andrews Community Hospital has x-ray facilities. Should the Health Board choose to arrange overnight, on call cover for radiography, then the out of hours service is fully equipped to meet the requirements of an urgent care centre. It has access to patients’ records and the internet and has the ability to communicate with other professionals. It has a supply of emergency medicines and clinical equipment suitable for children and adults including resuscitation equipment

Clinical equipment includes, – urinalysis, glucometer, INR testing, ECG, pregnancy testing, peak flow meter, urinary catheters, nebulisers, intravenous cannulation, defibrillators etc.

Patients who need to travel to the Out of Hours Centre can access it from anywhere in North east Fife in less than the accepted 30 minute driving time from their home. The further people have to travel to access a GP the more likely they are to decide instead to travel to Ninewells Accident and Emergency Department. The St Andrews Out of Hours Centre provides home visits to patients whose medical condition prevents them from travelling, patients who are housebound, patients with long term conditions and prior to the two decisions taken by NHS Fife mentioned above (fevered children to attend VHK and emergencies deflected away from GPs) attend emergency calls and visited young children in their homes. The GPs also provide vital and sometimes time consuming cover for inpatients on the wards and hospices in the two community hospitals (60 beds). The rural nature of North East Fife may put extra pressure on the GP to make home visits based not just on clinical need but on safety of the patient during poor weather and road conditions, for they have access to a 4 wheel drive vehicle.

There ought to be the same determination to meet the health needs of the rural community of NEF with a high number of older people and pockets of deprivation as there is to meet the needs of the people surrounding Kirkcaldy and Dunfermline with their higher levels of deprivation.

Mary Mathewson,
Address supplied

Footnotes