NHS Lothian on road to recovery

NHS Lothian Chief Executive Tim Davison. Picture: Ian Georgeson
NHS Lothian Chief Executive Tim Davison. Picture: Ian Georgeson
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THE NHS employs around 24,000 people in Lothian and in the unlikely event you don’t call on it in some form in the year ahead, someone close to you will.

So it is in all of our interests to know how our region’s health service is being run, the challenges it faces, what changes will be made and crucially, what impact it all might have on us and our loved ones.

In Lothian, the NHS has come under especially intense scrutiny in recent years, following high-profile scandals around waiting times and bullying. And while progress was made last year, obstacles have yet to be overcome. This year promises to be a vital one.

Here, we look at eight key areas for NHS Lothian, with analysis informed by senior figures within the health board, including chief executive Tim Davison, union officials and other insiders speaking in confidence.

In 2014, health bosses hope that waiting times will finally be brought under control – something that it had been predicted would be done by the middle of last year. But doubts remain, particularly over the ability of facilities such as the Princess Alexandra Eye Pavilion, which it has been admitted is not fit for purpose, to cope. A necessary, but nevertheless unhealthy and expensive reliance on the private sector, will continue. The fundamental problem facing NHS Lothian – that it does not have the capacity to meet rising demand itself – remains.

“Generally, we’ve undertaken enormous effort and made really good progress in three of four areas [inpatients, cancer and endoscopy] but outpatients particularly remains a huge challenge,” Mr Davison admits. “It’s like you fix the problem here, and another one pops up over there. It’s relentless. We’re never going to be able to go ‘well, that’s waiting times fixed’.”

Huge projects, such as the building of the new Sick Kids Hospital at Little France and a long-overdue redevelopment of the Royal Edinburgh Hospital, are due to get under way.

All this takes place against a backdrop of a fundamental cultural shift in the health service. Experts are agreed that more of us need to be cared for in the community rather than in hospital – something that is vital as the population grows larger and older. It is hoped that 2014 will be the year that extensive behind-the-scenes work will reap tangible rewards, in particular in turning the tide to reduce bed-blocking.

The future of our NHS could depend on it.

UNSCHEDULED CARE

LAST winter proved one of the most challenging ever for NHS Lothian, and while the picture was repeated across Scotland, the undersized Royal Infirmary performed disproportionately poorly.

Whether that chaos, when Lothian’s flagship hospital ran out of beds and record numbers of patients faced waits of 12 hours or more in A&E, will be repeated remains to be seen.

The coming months will no doubt prove challenging, but if another crippling norovirus outbreak is avoided, our hospitals are likely to fare better, with the region’s emergency departments’ performance currently in line with the national average after a huge influx of staff.

All-too-familiar issues with the Royal Infirmary’s PFI owner and operator Consort meant 31 desperately-needed new beds will come too late for the worst of this winter, to the exasperation of NHS bosses, but with work already well under way and a completion date of February, they will prove valuable later in 2014.

Work is also ongoing to find a long-term solution to bed-blocking – when patients become stuck in hospital taking up expensive hospital beds because care home or home care packages are not available.

NHS Lothian chief executive Tim Davison, pictured, says shifting the balance from hospitals to the community presents “the biggest challenge we’ve got around unscheduled care”.

It’s a problem that has been getting worse for several years, but Edinburgh City Council, which by the latest estimate needs to provide 5000 extra home care hours a week and 80 care home places, is yet to show it has the cash or the determination to fix the issue.

A plan for the NHS and the local authority to pool its surplus land to raise cash or attract developers to finance new care homes is welcome, if nothing else because it shows a degree of imagination that has thus far been lacking in finding a solution.

But even if it proves a runaway success, care homes do not spring up overnight and bed blocking will continue to frustrate throughout 2014.

FINANCE

CASH will become increasingly tight next year in the region’s NHS, despite a funding boost from Holyrood.

NHS Lothian’s budget will increase by £48 million in 2014-15, however, a pay award to staff, building projects, spiralling energy bills and increases in staffing will see costs rise by £86m.

The health board missed its efficiency savings target last year and is off-course to hit it this year, so it is becoming increasingly difficult to see how it will it find £38m – around 3.5 per cent of its budget – next year.

Added to that is the grim news that changes to the funding formula used to distribute cash between health boards, in addition to a lower than expected population rise, means that NHS Lothian will receive £30m less than was expected after next year.

It will not directly affect next year’s budget, but it will mean that health chiefs will have to re-evaluate some of their longer term plans.

WAITING TIMES

WHEN Tim Davison was appointed as NHS Lothian’s permanent chief executive 17 months ago, he confidently predicted that waiting times would be under control by the middle of 2013.

However, the issue has proved more complex than first feared when it emerged in late 2011 that figures had been fiddled on an industrial scale, meaning thousands more patients than had previously been known about were waiting beyond a 12-week target to be seen.

While progress was made in 2013 – the number of patients waiting longer than they should fell from around 2000 to 350 and only a tiny proportion now wait beyond six months – it has been frustratingly slow.

A nightmare summer also meant that the numbers waiting beyond 12 weeks for outpatient appointments soared, almost to the same level as at the peak of the waiting times scandal. A decision to prioritise patients with more serious conditions at Princess Alexandra Eye Pavilion was the right one, but it has done the headline figures no favours and those with reversible conditions like cataracts have paid the price.

Waiting times will continue to present a huge issue for NHS Lothian throughout 2014 and if you need a routine operation, there’s a decent chance you’ll be sent to a private hospital, with the health board still a long way from having enough staff, clinics and theatre slots to treat all of its patients itself.

Expect NHS Lothian to continue to struggle to

meet Scottish Government’s Treatment Time Guarantee, which the public were told would mean 100 per cent of patients would have a legal right to treatment within 12 weeks for many procedures. The law has been branded as unrealistic by some insiders and is becoming increasingly discredited with few health boards able to meet its demands.

BUILDINGS

THE long-awaited replacement of the Capital’s Sick Kids hospital is one of the most exciting health projects in NHS Lothian’s history.

It has not been a simple journey, with the hospital already delayed by several years, but a preferred bidder to build and run the hospital should be selected within months and construction should begin by the autumn.

The new Sick Kids, which will also house NHS Lothian’s Child and Adolescent Mental Health Service and the Department of Clinical Neurosciences, should provide a world-class facility to match the talent and dedication of the health board’s staff.

However the project presents unique challenges which will need to be carefully managed. The new hospital will be built at Little France and “plug in” to the Royal Infirmary – one of the busiest hospitals in Scotland. It is a logistical nightmare by anyone’s standards.

And if that wasn’t enough to cause NHS chiefs sleepless nights, the hospital is being financed by a non-profit distributing model, a similar, although better value, arrangement to the Private Finance Initiative deal which has proved a disaster at the Royal.

It means two private firms – motivated by profit – will be working alongside the NHS across two major hospitals on the same site. The seemingly never-ending issues between NHS Lothian and Royal Infirmary owner Consort do not inspire confidence that all will run swimmingly.

Delays and blown budgets have already been reported in the work to simply get the site ready, so don’t be surprised if there are more hiccups along the way.

Elsewhere, the first phase of a much-overdue rebuild of the Royal Edinburgh Hospital will begin, with hopes high that the opening date could even be brought forward.

Expect progress to be made on new multi-million pound health and community hubs in North Edinburgh, Firrhill and Blackburn, with other NHS building projects ongoing in Tranent, Ratho, Gullane and the city’s West End.

PATIENT SAFETY

ONE of the more alarming episodes of 2013 centred on safety in NHS Lothian operating theatres.

An internal probe was launched after a patient plunged head first from an operating table and another was left in intensive care after a medical instrument was sewn inside them.

It then emerged that at least ten similar avoidable incidents had taken place in a year, with poor teamwork between theatre staff, who were often distracted by idle chat and mobile phones, among the revelations uncovered by the investigation.

While the findings were undoubtedly shocking for a health board that states patient safety is its absolute top priority, it is to NHS Lothian’s credit that issues that may once have been hushed up were investigated promptly and thoroughly.

And it is reassuring that over 2014, action will be taken to address the problem.

Thousands of staff are to be trained in “human factors” – a progressive scientific approach to eliminate errors that has also been used in the aviation, off-shore oil and nuclear power industries – and strict new rules will be brought in. The chances of falling victim to a surgical blunder were always remote, but that will be no consolation to the unlucky few. By 2015 it is hoped they will be all but eliminated.

Lothian health bosses are also set to study a recently published report into NHS Lanarkshire – which found serious problems with understaffing, quality of care and patient record keeping – in coming moths.

While NHS Lothian does not share Lanarkshire’s high mortality rates which sparked the probe, some of the 21 recommendations could be adopted to improve services.

CULTURE

IN 2012, NHS Lothian became embroiled in a bullying scandal, which in addition to revelations over manipulation of waiting times statistics, caused damage to the health board’s reputation which is a long way from being repaired.

After an extensive exercise involving thousands of staff, a new set of values was agreed in 2013, with senior management keen to publicly emphasise their desire to improve openness and accountability.

The recent results of an NHS Scotland staff survey, however, showed 17 per cent of NHS Lothian staff – more than any other health board in Scotland – reported bullying from a colleague, while more than one in ten had experienced harassment from a manager.

The findings showed that an issue still exists in NHS Lothian, but senior bosses are confident improvements will continue in 2014 with meaningful change in an organisation with 24,000 staff not likely to occur overnight.

And unions – not shy of speaking out – are happy that bosses are giving the issue the attention it deserves.

“We’re content that they’re taking it seriously and we’re moving in the right direction,” Unison’s Tom Waterson, pictured, says. “But there’s always more that can be done and we’re always looking at ways we can improve systems to make it easier for staff to come forward.”

STAFFING

HEALTH boards are increasingly operating in a worldwide marketplace when it comes to attracting the most sought-after medical staff.

Planning blunders of the past meant that in some professions there are simply more jobs than there are trained workers to fill them across the UK.

And with an increasingly female workforce leading to a higher proportion of staff taking maternity leave or working part-time, health chiefs accept that the appeal of Edinburgh can no longer be relied on to tempt enough doctors to the Lothians.

Imaginative solutions have already paid dividends – a recruitment drive that spanned the globe has meant that for now at least, the paediatric ward at St John’s Hospital will remain open 24-7.

An innovative plan that saw junior doctors offered one-year jobs at St John’s Hospital A&E also prevented a substantive downgrade of the facility. The move has proved such a success that it could be rolled out at the Royal Infirmary in 2014.

But NHS chiefs cannot rest on their laurels, with a staffing crisis in the Royal Infirmary’s maternity unit next on the agenda.

It is hoped that two teams will be created to work separate rotas to alleviate strain on overworked staff and make the posts more appealing.

But it relies on attracting new workers to the hectic, stressful jobs, from an ever-smaller pool. To do that, the health board needs to make the jobs as attractive as possible.

Pay rates are set nationally, but NHS Lothian could offer to pay for Masters degrees for staff and re-examine working conditions in a bid to fend off competing organisations.

MENTAL HEALTH

OUR major hospitals and treatments for diseases like cancer may take up more column inches, but urgent action is needed to address a rapidly worsening picture in mental health.

In December 2014, tough new targets will come into force in a bid to speed up treatment for the ever-increasing number of patients in need of psychological therapies.

As it stands, NHS Lothian is a million miles away from meeting those, and performance is getting worse rather then better.

The health board has committed just £700,000 to improving the situation in 2013-14 – a pathetic sum when it is considered that more than £32 million will be spent in the same period on speeding up treatment in acute hospitals.

A review of provision will be completed shortly, but it is clear that a significant injection of cash will be needed fast if the new targets are to be met – and NHS Lothian chief executive Tim Davison accepts that more spending is necessary.

In more positive news, a huge redevelopment of the Royal Edinburgh Hospital is gathering pace, with building work on its first phase to begin within months.

But with the first buildings not due to open for at least three years, action to improve the short-term situation is needed urgently.

If it doesn’t happen, public declarations that mental illnesses are no less serious than physical conditions will be shown to be no more than empty soundbites.