Image: Maidstone & Tunbridge Wells NHS Trust

Last week the Care Quality Commission (CQC) issued a critical report on Maidstone Hospital. You can be forgiven for not having read it – it’s not the worst I’ve seen by any means and didn’t get much national coverage. But hidden within it are some alarming messages for the many trusts responding to public and political pressure to keep as many services as possible at smaller District General Hospitals (DGHs).

First the history. Maidstone and Tunbridge Wells centralised some services at the newly-built Tunbridge Wells hospital in 2011. It’s 40 minutes drive from Maidstone and there was considerable pressure to keep services in Maidstone. It retained a 24/7 A&E (though major cases go to Tunbridge Wells), and now does most planned surgery for the trust and also has a successful midwife-led maternity unit. It has no overnight facilities for children.

A sustainable future? The trust seems to think so – and, to its credit, seems genuinely keen to keep as many services as possible there despite financial and clinical challenges.

But the CQC report seems to raise questions over this – and by implication for other trusts following/considering similar models.

Paediatrics

There is a day unit for children but no overnight care. However, some children will be brought to A&E by their parents outside normal hours and there will not be a paediatric resuscitation team to manage them. I suspect this is true of most hospitals which offer ‘minor’ A&E care but don’t have children’s beds. Out of hours there was not always a paediatric nurse on duty (the trust employed one paediatric emergency nurse practitioner but obviously they could not cover all shifts). Royal college guidance says A&E departments seeing children should employ enough paediatric nurses to have one per shift. That may be a challenge for smaller units: the alternative is that every child with a stubbed toe has to go to a major A&E with this level of staffing.

Maternity

The trust was criticised for there not always being a paediatrician or neo-natal support services available in the event of a pre-term delivery ‘in A&E.’  Does this invalidate any standalone midwife led unit, the vast majority of which, by their nature, won’t have this type of support available?

Surgery

Some staff work across both sites and there were times when the consultant in charge was on another site, leaving junior doctors to operate without their physical presence. Emergency demands at TW meant that staff grade doctors had been employed to help with planned surgery at Maidstone. Some of these were high risk but with little consultant input.

Some of this may relate to job planning and a hot-cold separation which still leaves consultants with concurrent responsibilities at both sites. But operations at many trusts take place without the presence of a consultant because they are out of hours and at weekends. However, many specialties would struggle to timetable surgery to allow for continuous consultant presence onsite during a procedure and its aftermath – let alone if the patient develops complications some time later.

Some of what is detailed in the report is inexcusable and is within the trust’s gift to put right. But I suspect that not all of this can be rectified within the current set up at this or other trusts. Some of the CQC’s criticisms seem to push the centralisation agenda – a model where a consultant is always on site, where enough children are seen to justify 24/7 paediatric nurses in A&E, and where babies are born under the gaze of a paediatric resuscitation team. If smaller DGHs are to meet these standards they will be reduced to community hospitals with limited A&E, no births and no surgery. That might be safer but might well be unpopular with both public and politicians. Which way are hospital managers expected to jump?

One final thought: some staff work across both sites and have to travel during their working day – and often end up doing so in their lunch hour.  The trust won’t pay mileage to many of them and insists they use the shuttle bus. I hear that this does not always correspond with clinic times, meaning staff have to run out of the door at one site to catch it – or risk being late for clinic at the other. Not likely to make staff feel appreciated and valued.

This article is cross-posted from 'NHS Hack'