Burnley Urgent Care Centre (UCC) Review March 2010
Comments by Gordon Prentice MP
1 Overview
1.1. This review by Professor Cooke and Dr Cobden has a narrow focus: how can the performance of the Burnley Urgent Care Centre be improved?
1.2. I believe the reconfiguration as originally conceived was flawed. It has never met the expectations claimed for it. My preference would be the return of a blue light A&E at Burnley General with a publicly available protocol making it crystal clear which conditions could or could not be treated there.
1.3. The key element of the Meeting Patient Needs (MPN) reconfiguration programme was that Royal Blackburn Hospital was to be developed as the ‘Emergency/unplanned’ site and Burnley General hospital as the site for all planned work. The principle of splitting the unplanned and planned work across two East Lancashire sites was sold to the public as a way of delivering improved services to patients and the more effective use of resources.
1.4. However, the implementation of the changes across the NHS in East Lancashire has not achieved all the forecast promised improvements. Blackburn’s Emergency department has consistently failed to reach government performance targets and the patient experience has been consistently poor. While, at the same time, the initial targets set for patient throughput at Burnley’s UCC has consistently been under achieved. The situation is that Blackburn is frequently unable to cope with the number of ‘emergency’ patients turning up for treatment while Burnley’s UCC has been under utilised in terms of patient numbers.
1.5. The reconfiguration of the secondary health care for East Lancashire has resulted in a reduction in mortality rates. This is primarily a result of establishing a well equipped specialist coronary unit attached to the emergency department. Co-location has, indeed, made a difference.
1.6. However, this does not mean that outcomes cannot be further improved by re-examining the overall operation of the health economy of East Lancashire and ensuring that patients are treated at the most appropriate facility. It is a fact that Blackburn Emergency Department is attracting many patients who could be seen at Burnley. And, for its part, Burnley is under utilised for appropriate patients and is not relieving the pressure on Blackburn.
1.7. Below is a more detailed consideration of the issues raised:
2 Blackburn is not coping
2.1 The tables below contain data extracted from the Department of Health’s Acute Hospital Trust performance statistics.
2.2 East Lancs Hospital Trust (ELHT), (i.e. RBH and BGH) is around 24th most attended in England out of 257 hospital trusts.
| Year/Quarter | Attendances | Most attended from 257 trusts |
| 2009/10 Q3 | 35,784 | 24th |
| 2009/10 Q2 | 36,685 | 24th |
| 2009/10 Q1 | 38,378 | 21st |
2.3 ELHT has only once achieved the government’s benchmark target of attending to 98% of patients, or more, presenting at A&E within 4hours. The performance and rank within the 154 acute trusts is amongst the worst in England.
| Year/Quarter | % seen within 4 hours | Rank (worst) from 154 trusts |
| 2009/10 Q3 | 97.44 | 39th |
| 2009/10 Q2 | 96.38 | 2nd |
| 2009/10 Q1 | 94.5 | 1st |
| 2008/09 Q4 | 94.31 | 3rd |
| 2008/09 Q3 | 95.13 | 6th |
| 2008/09 Q2 | 98.72 | 10th |
2.4 This is aggravated by having insufficient beds available for A&E patients waiting to be admitted. Again the ELHT has recently been the 12th and 17th worst for lack of bed availability out of England’s 154 Acute Trusts.
| Year/Quarter | % not in bed within 2hrs after decision to admit | Rank (worst) from 154 trusts |
| 2009/10 Q3 | 54.9 | 12th |
| 2009/10 Q2 | 65.3 | 17th |
3 Burnley is under-utilised
3.1 When Burnley had its own A&E department (2007) it is estimated that there were around 68,700 attendances.
3.2 The MPN estimate was that 85% of 2007 Burnley attendances would be appropriate for attending the new UCC at BGH, that is around 58,400 attendances. The actual number of attendances through BGH UCC is running at around 4,000 per month, that is 48,000 per year or 69% of the 2007 figures.
4 Burnley can justify an A&E facility based on attendances
4.1 The last year (2003) when separate figures were published for A&E at Burnley, there were 61,997 attendances. Figures published in 2008 for all Hospital Trusts in England showed around 45 Accident and Emergency Departments had fewer patients admitted than Burnley General Hospital did in 2003 when the East Lancashire Hospitals NHS Trust was formed.
4.2 Professor Alberti, the ex-National Clinical Director for Emergency Access, said: “In particular, the volume of patients (at Burnley) would not justify the employment of the specialist clinicians required to sustain an emergency service and such a service would be unsafe and detrimental to meeting the needs of patients.” Figures from the Department of Health for 2008 show that 145,055 people attended the single A&E in East Lancashire.
4.3 Also, 131,689 people went to A&E in the Calderdale and Huddersfield NHS Foundation Trust where there are two Type I A&Es, at Halifax and another at Huddersfield. In the Lancashire Teaching Hospitals NHS Foundation Trust there were 115,057 attendances at the two Type I A&Es at Preston and at Chorley.
4.4 There are many Hospital trusts around the country where A&E attendances are less than the volumes handled by Burnley when it had its own blue light emergency department, handling 61,997 attendances: Yeovil (42,119); Scarborough (48,841); Harrogate (41,040); Airedale (50,872) plus others.
5 Mortality rate improvement not based on A&E reconfiguration
5.1 To what extent can improvements to mortality be attributed solely to the single A&E at Blackburn? The claim is often made that 200 lives have been saved as a result of the transfer of A&E to Blackburn.
5.2 Hospital Standardised Mortality Ratios (which throw up the 200 figure) reflect mortality across the Trust – not on individual hospital sites. Some busy Hospital Trusts may have two, three or even four A&Es. In these circumstances, the Hospital Standardised Mortality Ratios could not be use to distinguish performance across the various sites.
5.3 The Health Secretary has put in hand a review of HSMRs because of the confusion over their use and the claims which are often based on them.
5.4 Lives have been saved. But the question before us is whether more lives still could be saved with a different configuration – by reinstating A&E at Burnley.
5.5 The report on the implementation of MPN for the National Clinical Advisory Team (NCAT), of January 2009, stated that “Improvements in clinical outcomes for patients are striking, for example, deaths of cardiac patients in hospital having halved from 15% to 7% and deaths within 30 days following discharge having reduced from 19% to 10%, a total reduction of 92 deaths.”
5.6 I take the view that the improvement in mortality is due to the reorganisation and development of a Consultant–led cardiology service from October 2007. The number of Consultant Cardiologists was doubled to 6 and Consultant Cardiologists replaced General Physicians leading all aspects of the work of the unit. These changes led to a substantial reductions in the length of stay and a reduction in the ‘all cause’ in-hospital and thirty-day post discharge mortality in acute coronary syndromes. The Risk Ratio (RR) that calculates an expected number of deaths, allowing for the factors that affect the local population, adjusted to a 100 base line, has seen the non-elective coronary mortality RR drop from 124.1 in 2005/06 to 80.5 in 2009/10.
5.7 However, the total non-elective mortality RR has fallen from 121.9 in 2006/07 to 105.2 in 2009/10 but this still equated to 32 more deaths than ‘expected’ for 2009/10 (i.e 658 deaths against an expected 626).
5.8 The mortality rates have dropped substantially, but the majority of the improvement is due to the new Coronary Unit established as part of the reconfiguration. But this is not strictly an A&E change. The non-elective improvements still have some way to go to achieve statistically expected results.
6 Current emergency activity at BGH – Maternity and Ophthalmic Units
6.1 The Edith Watson maternity unit at Burnley is due to be replaced by a new Mother and Newborn facility in 2010. This will provide services for the whole of East Lancashire. There are currently emergency facilities available to the existing unit and these will be carried forward into the new unit.
6.2 Similarly, The Ophthalmic Unit at Burnley covers the work for the entire East Lancashire area, including emergency procedures. This meets the criteria for a Type II A&E.
6.3 This is anomalous given Burnley’s primary designation as an elective centre. But it does demonstrate that emergency work is routinely carried out there.
7 Ambulance performance significantly worse since reconfiguration
7.1 As part of implementing Meeting Patient Needs, three additional ambulances were purchased and extra staff recruited to cope with locating the single A&E department at Blackburn at the extreme western end of the area. Barnoldswick is 23 miles from Blackburn with an average journey time of 30 minutes. There was a promise at MPN that all ambulances would be staffed by at least one paramedic, that is, trained personnel who can deal with heart attacks and administer clot-busting drugs.
7.2 The North West Ambulance Service (NWAS) has confirmed that it has been unable to train enough paramedics to ensure that a paramedic is on every ambulance. Figures from 2008 suggest that 11% of ambulances are staffed with technicians who cannot administer clot busting drugs.
7.3 There have been significant performance issues with NWAS in East Lancashire. Figures show that the performance in Burnley, Pendle, Rossendale, Hyndburn and Ribble Valley was 70.5% of category A calls being responded to in the target time of 8 minutes. The government target is 75%. The 70.5% in down from 74.6% average performance before the MPN reconfiguration.
7.4 For less serious, or ‘category B’ cases, with a 19-minute requirement, the performance is 91.3% against a target of 95%.
7.5 The situation for the emergency callers from the east of the area is even worse, with BB18 (Barnoldswick area) having an average category A, 8-minute response performance of 55% between May and October 2009, against a target of 75%.
7.6 There is anecdotal evidence from paramedics that ambulance crews spend a disproportionate amount of time in the Blackburn area, because of queuing at RBH and because they get redeployed within the Blackburn area when they become free from the hospital queue because they are the nearest crew. This would explain the very poor performance in the Pendle and Ribble Valley areas.
8 Slow progress implementing an effective ambulance emergency protocol
8.1 Recently 10% of ambulances went to Burnley and 90% went to Blackburn. The Burnley deliveries were non-emergencies, usually GP referrals. There has been an attempt to establish a protocol that would enable ambulance crews to phone an emergency senior medic to help to decide whether a particular patient should be delivered to Burnley or Blackburn depending upon the severity of the case. The general impression is that this procedure has not been successful and too many cases are being referred to Blackburn unnecessarily.
8.2 A review of the operation of the ambulance telephone advice service ha been underway since January 2010. The review includes carrying out an on-going audit of cases arriving at Blackburn from the Burnley area to assess if they could have been handled appropriately by Burnley. The Medical Directors of NWAS and ELHT are liaising on this.
9 Very poor Patient and Public understanding of MPN changes and the impact on service provision
9.1 It has been generally accepted, since the start of the implementation of MPN, that public support for the changes was paramount. This has never happened. There has been constant hostile press coverage of the changes and all local political parties have spoken against the changes to emergency services, particularly for the populations of Pendle, Burnley, Rossendale and Ribble Valley.
9.2 Attempts have been made by the Primary Care Trusts and the East Lancashire Hospitals Trust to inform residents of the alternative services provided at Burnley and Blackburn but the attendances at Burnley are constant, month on month. This indicates an ignorance of the services available at Burnley or a reluctance to chance a self-referral there.
9.3 The Lancashire County Council Health Overview and Scrutiny Committee established a special task group to review the implementation of the MPN changes. A number of recommendations concerned communication with the general public. The O&SC Task Group report was reviewed in early February 2010 to monitor progress. Recommendations concerning (a) communicating the need for change and ‘how each stage of MPN is being implemented’ and (b) proving publicly that “the reconfiguration is giving better outcomes for patients” have got nowhere. Neither of these recommended actions has been completed and an update is due in July 2010.
10 Population health-care access better served by Burnley site
10.1 During the MPN consultation the split between a planned hospital site and an emergency/unplanned hospital site was given a good airing. However, the option of keeping the emergency site at Burnley was rejected on financial grounds.
10.2 The Burnley site is more central geographically than Blackburn. The attendances at Blackburn and Burnley A&E’s prior to the merger of the two hospital trusts was very similar with Burnley having 48% of attendances (62,000) and Blackburn having 52% attendances (68,000).
| Population in thousands | 1991 | 2001 | 2008 | % Increase | Average closest Site |
| Blackburn with Darwen | 137.4 | 138.5 | 140.7 | 2.4 | RBH |
| Burnley | 92.0 | 89.5 | 87.3 | - 5.1 | BGH |
| Hyndburn | 78.6 | 81.5 | 81.6 | 3.8 | RBH/BGH |
| Pendle | 85.5 | 89.3 | 89.9 | 5.1 | BGH |
| Ribble Valley | 51.8 | 54.1 | 58.5 | 12.9 | BGH |
| Rossendale | 65.8 | 65.6 | 67.3 | 2.2 | BGH |
| East Lancashire | 511.1 | 518.5 | 525.3 | 2.7 | |
10.3 So, the population that accessed Burnley is disadvantaged as a result of the reconfiguration in terms of access to an A&E facility. Population trends as shown above are likely to make the disadvantage even greater.
10.4 The fact that Blackburn is in the south west corner of the East Lancashire area leads to significantly longer journey times for patients and patient’s visitors who are going there. Particularly, public transport services mean long journeys to Blackburn from Pendle, Burnley and Ribble Valley. The journey to Blackburn is seen as much worse than the journey to Burnley particularly for the elderly and the infirm. The eastern parts of Pendle are around 23 miles from Blackburn and 10 miles from Burnley.
10.5 Ambulance performance figures are affected by the long journey times to the east and north of the region (See section on Ambulance Performance).
11 Patients Choosing Airedale A&E
11.1 Figures supplied by the East Lancashire Primary Care Trust show that significantly more patients prefer to use the Emergency Service at Airedale Hospital than was planned. The figures below refer to Pendle Locality activity which includes the patients most likely to choose Airedale because of its closeness to the Pendle towns.
11.2 The resulting shortfall in actual income that was planned for the East Lancashire Hospital Trust must be affecting resource availability at the hospital trust. The return of an emergency Department to Burnley would redress this outflow of funding.
Pendle Locality A&E Activity to month 7 of 2009/10
| | Activity | Budget to Date (£) | Actual to Date (£) | %age of Total cost (%) | Variance (£) |
| Airedale | 3,405 | - | 291,314 | 20.43 | 291,413 |
| ELHT | 14,139 | 1,140,604 | 1,111,493 | 77.96 | -29,011 |
Gordon Prentice MP
25 March 2010
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