A report commissioned by Richmond MP Rishi Sunak into changes at the Friarage suggests the decision to replace the A&E unit with an emergency treatment centre was sound.
The independent study describes the controversial changes as “innovative” and says the move “maximises access to care for local people”.
The report looked at A&E services across the UK and found that it was extremely rare for a hospital of the Friarage’s size to be able to maintain full A&E provision, and much larger hospitals had already had make similar changes due to similar staffing issues.
The report’s authors also found that patient safety should be protected under the new care model that also ensures more sick children are treated at the Northallerton hospital than previously.
The MP commissioned the report from healthcare management consultancy Carnall Farrar after the South Tees Hospitals NHS Foundation Trust, which runs the Friarage, announced it was changing the A&E department to an urgent treatment centre at the end of March because of a shortage of doctors.
The report found:
- The trust’s estimate that only ten per cent of patients who would have attended the old A&E and have to be treated elsewhere has proved to be correct
- Experience elsewhere shows a small increase in ambulance travel times for a small number of patients does not lead to increased patient mortality. Patients with time-critical illness are not affected.
- The new urgent treatment centre has treated almost 40 per cent more children than were looked after in the old A&E department
- While the trust could have done more to recruit overseas doctors in the past, it is not clear that this would have been a sustainable solution for the Friarage.
- The trust must step up its efforts to recruit and train the emergency nurse practitioners needed to staff the enhanced urgent treatment centre
Mr Sunak said he commissioned the report to ensure that he, as someone who is not a medical expert, had the independent expertise and advice to effectively hold the South Tees Trust to account for its actions and proposals.
Carnall Farrar has previously completed a number of reports focussing on both regional and national healthcare services.
The review team who compiled the report included a partner in the consultancy with over 32 years in the NHS, a consultant anaesthetist and an analyst who worked for a number of years as a medical clinician in A&E and critical care departments in the NHS.
The consultants put together the 79-page report with in-depth, independent analysis and modelling. They reviewed extensive literature and held interviews with key people including the Royal College of Anaesthetists, the Royal College of Emergency Medicine, the Yorkshire Ambulance Service and the South Tees Trust.
Mr Sunak asked Carnall Farrar to address three critical questions concerning the changes to emergency care at the Friarage hospital:
1. What has been the experience of A&E departments at similar hospitals to the Friarage? What challenges have they faced and what measures have they implemented?
Analysis found:
- The Friarage is very unusual in maintaining a full-service A&E given the size of the hospital and patient volumes that it sees
- The Friarage currently has the smallest A&E in England. The next largest full-service A&E has 70% higher patient volumes
- The only smaller UK hospitals that have sustained full A&E provision are all in Scotland. Three are on islands and the remainder serve extremely remote areas.
- Since 2009 approximately 17 hospitals have downgraded their A&E provision largely due to the difficulty in recruiting the right doctors to work in A&E and intensive care. This was despite these hospitals having larger patient volumes than the Friarage.
2. Has the trust made a genuine case for change in the emergency provision at the Friarage? Were any opportunities to maintain the provision missed? Were all possible recruiting avenues explored to preserve A&E services?
The report concluded:
- National clinical guidance from the Royal Colleges dictates appropriate staffing levels; the trust has been unable to meet the requirements to run a safe service
- The trust has been unable to attract key critical care doctors needed to run an A&E, largely because of doctor appetite and increased specialisation of the profession
- It is a common theme across the UK for smaller hospitals to struggle to attract specialist A&E doctors
- Workforce challenges have escalated and it was reasonable to implement the changes in order to safely run an urgent care service.
- The trust could have been focused more on overseas recruitment, but even this would not guarantee a different outcome
3. Is this temporary model appropriate for the specific needs of our rural community and is it sustainable for the future?
The healthcare consultancy found:
- The enhanced urgent treatment centre model with a clinical decisions unit maximises access to care for local people compared to a typical UTC
- The trust’s forecast that only 10 per cent of the old A&E’s patients will need to be treated elsewhere has proved to be correct in the early weeks of the temporary closure.
- Changes at the Friarage should have minimal impact on the neighbouring James Cook and Darlington hospitals.
- Travel time analysis and clinical studies evidence suggests there should be no impact on patient mortality as a result of the changes and change in travel patterns
- There is an opportunity to significantly increase the number of sick children seen at the Friarage
- Implementing the new model of care is dependent on having an adequate workforce to deliver. The trust needs to have an increased focus on developing existing nurses as emergency nurse practitioners and recruiting new staff as required
- Failing to do this will impact accessibility
Following publication of the report Mr Sunak said: “The report clearly shows that the Friarage is not alone in facing these staffing challenges, and indeed many much larger hospitals have had to make similar changes to their A&E provision.
“It also concludes that the trust has a reasonable case to make changes, that the new care model can be safe and effective, and that it will increase the number of sick children that can be treated at the Friarage.
“I will continue to push the Trust to ensure proper recruitment and training of emergency nurse practitioners for the new model, as the report highlights this is something that needs to be a priority so that accessibility is not compromised.”
The MP said the Publication of the report, which was originally scheduled for the end of April, was delayed to ensure the report was comprehensive in its assessment of other similar-sized hospitals around the UK and for the review team to have two months’ worth of data to examine from the changes made at the Friarage at the end of March.
The changes to emergency care services at the hospital are temporary pending a public consultation process due to be held in September.
To read the report in full click here.
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