Labour: 100 days to pull NHS back from the brink

Labour pledges a relentless focus on the NHS in its first 100 days in government as new research reveals hundreds of “extreme” risks to patient and staff safety in hospitals across England.

The long-term impact that Tory and Liberal Democrat underfunding is having on our health service is exposed in official NHS Trust documents.

Analysis of more than 120 Trust board papers shows NHS Trusts are faced with hundreds of risks to patient safety classed as “catastrophic” or “extreme”, with the majority linked to lack of spending, staffing shortages or the failures of privatisation.

In government, Labour will immediately undertake a full audit of the risks revealed by the research and prioritise capital spending - which Labour has already allocated - to ensure people and buildings are made safe.

Risks linked to privatisation of the NHS include: 

• A Virgin Walk-In Centre at Coventry and Warwickshire Trust has had two cases resulting in patients dying. A coroner subsequently recommended patients be assessed in 15 minutes, but that has not been implemented – apparently because Virgin’s contract does not clearly stipulate the 15 minute requirement. Virgin has been sent two performance notices but its contract has been extended.
• An extreme risk to dermatology services at North Middlesex after private provider Concordia Specialist Care Services was liquidated and legal issues arose with its parent company Omnes.

Risks linked to capital and funding, often due to maintenance issues, include:

• A high potential of catastrophic failure of the roof structure of the Queen Elizabeth Hospital, King’s Lynn, due to structural deficiencies, posing a direct risk to life and safety of patients.
• At Morecambe Bay, where there are high levels of backlog maintenance on its aging equipment and “unsuitable environments for safe clinical care”, the hospital: is unable to deal with air pollution levels and consequently has closed the hospital’s day case theatres; and is currently monitoring patients’ bloods with a shared excel spreadsheet that is “demonstrably incomplete”.
• In County Durham and Darlington, the trust is at extreme risk of: failing to meet asbestos and fire regulations, and a total power failure across multiple sites. Units for cleaning endoscopy equipment are breaking down frequently, meaning that the equipment often has to be left uncleaned.
• The board of East Cheshire Trust warns that “If there are not enough CTG machines [for recording fetal heartbeat] to monitor high risk pregnancies on the maternity unit in the antenatal and intrapartum periods, then there is a risk that fetal compromise may not be identified in a timely manner”.
• At the Royal Derby Hospital, there is an extreme risk linked to the emergency buzzer system in the children’s wards. There sometimes is only one staff member working in the children’s high dependency unit (Dolphin ward) but they cannot easily request help in the event of an emergency because the nurse emergency buzzer system across the three children’s wards (Dolphin, Puffin and Sunflower) sound in the wrong place when triggered, and because there is no light alert to tell staff where the emergency is taking place. This is because they are configured to the previous building layout. The Board report indicates that this has been the cause of an incident previously.

Risks linked to NHS staffing include: 

• In Doncaster And Bassetlaw, there is an extreme risk to staffing of registered children’s nurses on two different sites, which could lead to children being harmed and delays to treatment.
• In Newcastle Upon Tyne there is an extreme risk of a shortage of radiologists affecting breast cancer screening.
• In Mid Cheshire, there are extreme risks: that a patient experiencing a cardiac event will be missed because of nursing shortages; of major harm to rheumatology patients after getting inappropriate care because of a shortage of consultants; and to dependant respiratory patients, either due to nursing shortages or because there are too few beds.
• At Southport And Ormskirk Hospital Trust, there is a catastrophic risk of inadequate staffing levels in the anaesthetic department due to burn out, sickness, annual leave or lack of sufficiently cheap agency staff. This could affect the safety of emergency, ICU and Maternity departments, and could mean that A&E would be closed to high risk patients, including children.

Last year (2018/19) there were 15,844 patient incidents “directly” related to estates and facilities services (an average of 70 incidents per acute, mental health and ambulance Trust) and 4,810 clinical incidents caused by estate and infrastructure failure. In 2018/19 there were also 1,541 fires recorded by NHS Trusts, and 34 people were injured as a result of fires. The cost to eliminate the backlog of maintenance repairs in NHS Trusts is now £6.5 billion. £1.1 billion of this is high-risk maintenance and repairs. 

NHS leaders have already warned this year that lack of investment in facilities was impacting patient safety. And last month GPs warned that winter pressures were likely to have an impact on patient safety, and 9 out of 10 hospital bosses felt staffing pressures were putting patient’s health at risk. 

Earlier this year the Chief Inspector of Hospitals at the CQC warned that the NHS had made little progress in improving patient safety over the past 20 years, and NHS Providers published research that showed 8 out of 10 trust leaders felt that reduced investment in NHS facilities was compromising patient safety. 

Jonathan Ashworth, Labour’s Shadow Health Secretary, said:

"These shocking reports reveal an NHS in crisis and on the brink.

"It is one thing for clinicians and managers to say what needs fixing, but we need a Labour government that will crack on and do it.

"We pledge that within the first 100 days of a Labour government we will get on top of this to ensure the extra funding we've promised is prioritised to keep patients and staff safe.

"The choice at this election is clear: five more years of the Tories running our health service into the ground - with more patients waiting longer for cancer treatment and operations, and more young people denied mental health care - or a Labour government on the side of patients and staff, with a rescue plan for our NHS."

Ends 

Notes to editors

Labour’s manifesto commits to:

• Ending NHS privatisation: Labour will end and reverse privatisation in the NHS in the next Parliament. We will repeal the Health and Social Care Act and reinstate the responsibilities of the Secretary of State to provide a comprehensive and universal healthcare system.
• Capital funding: Regarding the Party’s commitment to a £15 billion NHS capital investment over the Parliament: We will publish an infrastructure plan to return NHS England to the international average level of capital investment and to ensure future decisions are transparent and balanced fairly between every region. We will complete the confirmed hospital rebuilds and invest more in primary care settings, modern AI, cyber technology and state-of-the-art medical equipment, including more MRI and CT scanners.
• And safe staffing: Agenda for Change terms and conditions will be put into law alongside safe staffing limits for all staff. We will invest, train and develop NHS staff throughout their careers. We will introduce a training bursary for nurses, midwives and allied health professionals. We will remove the obstacles to ethical international recruitment. 

Labour reviewed the board papers of every non-specialist acute NHS England Trust in December 2019, including risk registers and board assurance frameworks. NHS Trust boards classify risks in different ways. This analysis uses a very common classification amongst different boards’ papers. According to that classification, risks graded 15/25 and higher are described as “extreme” and risks with a consequence graded 5/5 are described as “catastrophic”.

NORTH WEST

Blackpool Teaching Hospitals Trust, where estate configuration is “not fit for purpose” and the trust has a £34m underlying deficit, the trust is one of eleven in the country reporting a higher than expected number of deaths.

Integrated Performance Report (inc BAF)  Nov 19 p131

The board of Morecambe Bay Trust reported ‘unsuitable environments for safe clinical care’, including:

• An extreme risk to clinical environments. Air pollution in the hospital’s day case theatres is so high the Trust’s Infection Prevention team has banned them from being used as theatres.
• An extreme risk to patient safety because the Trust cannot monitor patients’ blood effectively, and is currently doing so with a shared excel spreadsheet that is “demonstrably incomplete”. Consequently it is “inevitable [that] follow up will be sub optimal”.
• An extreme risk due to high levels of backlog maintenance on its aging equipment.
• Another extreme risk to safe food preparation, citing dilapidated counters and inadequate electrical systems that could result in food not being kept at the right temperature and which could compromise hygiene.
• Extreme risk in out of hours ophthalmology. The only consultant on call has to cover a large area with no trained nurses to help. The board describe this as “inherently unsafe” for eye patients.

https://www.uhmb.nhs.uk/files/1715/7243/1229/Board_of_Directors_Reference_Pack_30_October_2019.pdf (pp. 96, 136, 61, 83, 130)

The board of East Cheshire Trust warns that:

• “If there are not enough CTG machines [for recording fetal heartbeat] to monitor high risk pregnancies on the maternity unit in the antenatal and intrapartum periods, then there is a risk that fetal compromise may not be identified in a timely manner”.

Sept Update p64

Mid Cheshire Hospitals NHS Foundation Trust’s board reported:

• Extreme risk of breast cancer patients’ outcomes could be damaged by breast imaging not being conducted on time.
• Extreme risks of major harm to rheumatology patients, either after getting inappropriate care because of a shortage of consultants, and to dependant respiratory patients due to nursing shortages or there being too few beds.
• Extreme risk that a patient experiencing a cardiac event will be missed because of nursing shortages.
• Extreme risks to workforce capacity and of registered nurse staff shortages, which may lead to adverse patient outcomes. https://www.mcht.nhs.uk/about-us/reports-and-publications/board-papers-and-minutes/2019-board-papers-and-minutes/?assetdet368664=26797 (p88 Board Assurance Framework, and Risk Register)

Warrington And Halton Hospitals NHS Foundation Trust board reports:

• An extreme risk that the hospitals’ staffing might become inadequate, potentially affecting patient care.
• An extreme risk of failure to maintain an old estate caused by restriction, reduction or unavailability of resources resulting in staff and patient safety issues, increased estates costs and unsuitable accommodation

Nov BAF p62

Southport And Ormskirk Hospital NHS Trust reports:

• Catastrophic risk of inadequate staffing levels in the anaesthetic department due to burn out/ sickness/ annual leave and lack of sufficiently cheap agency staff. This could affect the safety of emergency, ICU and Maternity departments, and could mean that A&E would be closed to high risk patients, including children.

https://www.southportandormskirk.nhs.uk/wp-content/uploads/2019/01/Public-Boardpack-Wed-6-November-2019-Print.pdf (p. 137)

North Cumbria University Hospitals NHS Trust lists numerous risks:

• “Current pressures” in nursing and midwifery are “stretching the trust to overcapacity”, with executives very concerned that experienced nurses would soon be replaced by inexperienced ones.
• Heart ultrasound scans may not be possible if there is no cover for annual leave of the Trust’s Consultant Cardiologist.
• Managers may not be able to fill Keswick’s Minor Injuries Unit due to a lack of nurse practitioners
• West Cumberland Hospital’s anaesthetics rota may not be filled.
• The Trust may lose some or all of its higher surgical trainees in trauma and orthopaedics

The board notes the “Freedom to Speak Up Guardian Report” that “behaviours are slipping”, due to pressure on staff.

BAF and CRR Oct pp. 42, 332, 41

Stockport NHS Foundation Trust’s board reports:

• Extreme risk of significant breaches of fire safety
• There is an extreme risk to patient safety due: to a lack of Haematology/ Transfusion staff, lack of to endoscopy capacity, staffing levels in maternity. 
• Extreme risk that patient care may be compromised, due to staffing shortages within ACU (Ambulatory Care Unit)  and Acute Medical Unit, and nurse shortages.

Nov BAF and RR

NORTH EAST

In Newcastle Upon Tyne Hospitals, the board reported “catastrophic” risks to patient care due to low capacity and high demand, and ten “extreme” risks, including:

• Failing to meet asbestos regulations
• Not being able to provide blood transfusions due to staff shortages
• Breast cancer screening being affected by a shortage of radiologists
• A total power failure across multiple sites
• Failing to meet fire regulations

http://www.newcastle-hospitals.org.uk/downloads/Board%20of%20directors/Trust_Board_Papers_-_26th_September_209.pdf

County Durham and Darlington NHS Foundation warned of ‘risks beyond tolerance’. 

• Units for cleaning endoscopy equipment are breaking down frequently, meaning that the equipment often has to be left uncleaned.
• Board papers state that University Hospital of North Durham’s A&E department is ‘‘unfit for purpose’ 
• Ambulance bays not staffed for 24 hours
  Pressure on cancer services at capacity breaking point

The board also warns that the Trust is unable to control the unsustainable backlogs for elective services, pressures on cancer services, and ambulance handover bays not being staffed for 24 hours.

https://www.cddft.nhs.uk/media/739329/trust%20board%20open%2025.09.19%20e-pack.pdf

The board of South Tees Hospital NHS Trust risk committee has noted that lack of funds is a risk to both the safety of their patients and the viability of the hospital itself, and reported unspecified “catastrophic” and “extreme” risks.

https://www.southtees.nhs.uk/about/board/meetings/2019-2020/ 

YORKSHIRE

Doncaster And Bassetlaw Teaching Hospitals NHS Foundation Trust’s board warns: 

• Of catastrophic risk because infrastructure has not been maintained and fire safety standards have not been kept to.
• Extreme risk due to risk of insufficient nurses caring for unwell children could lead to harm to children.
• Extreme risk of failing to adequately treat diabetes patients due to medicines being unavailable.
• And extreme risk that a flat roof could result in death because it hasn’t been properly protected.

https://oesn11hpbml2xaq003wx02ib-wpengine.netdna-ssl.com/wp-content/uploads/2019/10/PUBLIC-Board-of-Directors-29-October-2019.pdf 

Calderdale And Huddersfield NHS Foundation Trust’s board reported one catastrophic risk and three further extreme risks, including risks to:

• Staffing in radiology, nursing and A&E
• And long term financial sustainability.

https://www.cht.nhs.uk/fileadmin/site_setup/contentUploads/About_us/Publications/BoardPapers/BOD_2017/September_2019/Combined_Board_of_Directors_-_5_September_2019.pdf

Mid Yorkshire Hospitals NHS Trust’s board reports:

• Extreme risk of failure to maintain the safety of patients, to maintain and develop Trust estate and equipment 
• They have had to take action plans to mitigate the risk of suicides at the hospital.
• A high level of registered nurse vacancies, and an aging workforce.
• An extreme risk of not hitting targets or failing to meet standards.

https://www.midyorks.nhs.uk/download.cfm?doc=docm93jijm4n6459.pdf&ver=7989

WEST MIDLANDS

Coventry and Warwickshire Trust has “extreme” risks associated with how long Virgin’s Walk-in Centre is making patients wait.

• The Walk-In Centre has had two cases resulting in patients dying.
• The coroner recommended patients be assessed in 15 minutes, but that has not been implemented. 
• Virgin’s contract is unclear about whether or not its performance targets include patients being assessed in 15 minutes.
• Virgin was sent two performance notices.
• Nonetheless, Vigin’s contract has been extended.

https://www.uhcw.nhs.uk/download/clientfiles/files/TrustBoardNovember2019_compressed.pdf (p. 64)

George Eliot Hospital NHS Trust’s board reports a “catastrophic” risk regarding patient flow within urgent care not being managed effectively, the hospital missing performance targets, and the potential for delayed treatment and harm to patients. This risk also references ambulance handover delays and increasing length of stays in the hospital. The Trust lists four further “extreme” risks.

http://www.geh.nhs.uk/about-us/trust-board-of-directors/public-board-papers/?assetdet0572bb6c-ae6f-476f-95a2-8394ff9ec85f=9349&categoryesctl0572bb6c-ae6f-476f-95a2-8394ff9ec85f=977

EAST MIDLANDS

University Hospitals Of Derby And Burton NHS Foundation Trust

• At the Royal Derby Hospital, there is an extreme risk linked to the emergency buzzer system in the children’s wards. There sometimes is only one staff member working in the children’s high dependency unit (Dolphin ward) but they cannot easily request help in the event of an emergency because the nurse emergency buzzer system across the three children’s wards (Dolphin, Puffin and Sunflower) sound in the wrong place when triggered, and because there is no light alert to tell staff where the emergency is taking place. This is because they are configured to the previous building layout. The Board report indicates that this has been the cause of an incident previously.

Nov 2019 p148

United Lincolnshire Hospitals NHS Trust’s board reports:

• “Morale has declined significantly, pride in working for ULHT has gone down and staff feel that decisions are taken on the basis of finance, rather than patient experience and safety and to the detriment of staff (e.g. increase in car parking charges & controls over travel and training). There is significant cynicism amongst staff, which will not be resolved until they see action alongside the words  (Very high risk)”.
• There is a lack of fridge space at the Trust, which routinely stores medicines and IV fluids on wards in excess of 25 degrees (and in some areas above 30 degrees). Consequently, these drugs may not be safe or effective for use.
• There is a high risk that there will be a critical infrastructure failure disrupting aseptic pharmacy services (required for preparation of chemotherapy drugs and intravenous feeds for adults and babies).  This has been caused by issues with the age and condition of the facilities.

And reports numerous capital and infrastructure risks:

• Grantham and District Hospital’s aging electrical infrastructure and obsolete switchgear fails standards, and there is potential for it to fail, which could result in fire, and/or services being interrupted or closed. switchgear is obsolete and in need of replacing.
• Pilgrim Hospital’s electrical infrastructure is also in poor condition and needs significant investment to eliminate backlog maintenance and maintain capacity of the estate to deliver clinical activity.
• At Pilgrim, Grantham and Lincoln, numerous sets of fire doors in poor condition due to wear and tear and damage where the fire resisting qualities have been reduced or negated, so that they need to be improved in order to comply with fire safety standards.

CRR and BAF Items 17.1 and 17.2

Northampton General Hospital NHS Trust’s board says there is a catastrophic “risk of poor standards of care in ward and other areas due to inability to recruit adequate numbers of appropriately qualified nursing staff leading to suboptimal patient care and poor staff experience.”

https://www.northamptongeneral.nhs.uk/About/Our-Trust-Board/Meeting-and-papers/Downloads/Year-2019-PDF/Public-Trust-Board-28-November-2019-FINAL.PDF 

Sherwood Forest Hospitals NHS Foundation Trust’s board warns of an extreme risk of critical staff shortages, which could result in “prolonged, widespread reduction in the quality of services and repeated failure to achieve constitutional standards”.

BAF Nov 19

EAST OF ENGLAND

In North West Anglia NHS Foundation Trust, the board reported extreme risks, including:

• Patient safety risk due to theatre and radiology air handling plant room (4x5)  - level of control rated as inadequate 
• Inadequate legionella control
• A 33% level of radiologist vacancies meaning service cannot be maintained
• Failing heating system due to lack of maintenance and capital investment
• “Uncontrolled” failure to meet active treatment timescales in urology, risking premature death of patients 
• Insufficient medical cover for critical care services

Download Sept report.  BAF p98

Queen Elizabeth Hospital, King’s Lynn, says there is a direct risk to life and safety of patients, visitors and staff, due to catastrophic failure of the roof structure.

Luton and Dunstable Trust’s board warns that it “may have reached a tipping point in terms of the environment, cleaning and patient flow, all of which need to be scrutinised to stem the tide” and “no longer have a decant ward due to capacity issues”. Deep cleaning is reported to be necessary. Nov 19 Risk Register p255

Cambridge University Hospital NHS Foundation Trust reported numerous risks including an extreme risk of failure to address fire safety priorities due to funding issues. BAF and CRR p196

SOUTH WEST

Great Western Hospital NHS Trust reported extreme risks in a number of key areas including medical and nursing staffing levels, estates and equipment (containing ‘risk of  inability to Surgery/Procedures due to high risk that Sterile Service Equipment could fail’) and patient safety due to the inability to produce chemotherapy on site). 

Finance risks at the Royal Devon & Exeter NHS Trust are exacerbated by pay budgets are now that are overspent by £1.2m, largely related to medical agency costs due to gaps in staffing for middle and junior grade doctors.   The Board papers also report an extreme risk that National capital constraints impact on the Trust’s capital plans.  The Trust has also assessed as extreme this risk that a large proportion of the Trust’s 519 EU staff will leave the UK in the event of a no-deal Brexit and leave a gap in the workforce. This risk is higher for unregistered nursing staff and ancillary staff where the proportion of EU staff is larger.

SOUTH EAST

Buckinghamshire Healthcare NHS Trust’s board has reported:

• An extreme risk to services because the MRI scanner at Wycombe Hospital is “no longer fit for purpose and is producing imaging that is of unacceptable quality”, which may result in diverting patients to private provider Care UK.
• Extreme risk at Stoke Mandeville after one of its ultra clean air (“laminar flow”) theatres had to be shut down.
• An extreme risk that the budget will not be able to fund some high priority spending on medical equipment.

Nov 19 BAF and CRR p100-126

East And North Hertfordshire NHS Trust has a “catastrophic” risk that arrangements including fire management are so inadequate that they could lead to harm or loss of life, partly because of a lack of funding to pay for works at to bring the Lister and other sites.

https://www.enherts-tr.nhs.uk/content/uploads/2019/09/Sept-2019.pdf (p 304)

Surrey And Sussex Healthcare NHS Trust’s board reports extreme risks due to two ultra clean air (“laminar flow”) theatres have had to be shut down after their  ventilation systems and fire dampers failed standards, and a third has failed tests and so can no longer be used as an ultra clean air theatre. Consequently, the hospital has been unable to operate on a large range of orthopaedic procedures and its overall capacity has been significantly reduced.

https://www.surreyandsussex.nhs.uk/boardpapers/2019-board-papers/

LONDON

In Barts Trust, the board reported one “catastrophic” and six further “extreme” risks, including that:

• The Trust would not be able to comply with fire safety regulations if funding gaps stop it undertaking scheduled fire safety improvement works.
• And patients’ access to emergency care would be impacted by patient flow and capacity.
• Linked to this, the Board reported this Winter at Whipps Cross there was an extra risk of infection, and limits to facilities for isolating specific cases.

https://www.bartshealth.nhs.uk/download.cfm?doc=docm93jijm4n11173.pdf&ver=18296

 BAF Nov 2019 (p105)

North Middlesex University Hospital NHS Trust’s board is planning for 14 “extreme” risks, including an extreme risk to dermatology services after private provider Concordia Specialist Care Services was liquidated and legal issues arose with its parent company Omnes.

http://www.northmid.nhs.uk/Portals/0/Meeting%20on%20Thursday,%203%20October%202019.pdf?ver=2019-09-30-155339-550 (p. 27)

North Middlesex University Hospital NHS Trust reported 14 “extreme” risks including aging Gamma cameras regularly breaking down. 

 BAF Nov p27

The board of Imperial College Trust reported that 

• There was a “catastrophic” risk that critical equipment and facilities might fail, due in part to historic under-investment, current underfunding, and loss of staff, and resulting in longer waiting times.
• There was an “extreme” risk to A&E performance, in part due to inadequate ED estate
• The Trust’s Infrastructure had seen recent failures, reflected in serious incidents.
• Extreme risk of critical equipment failing. There is a “high” risk of constraints on funding for medical equipment, linked to a further 21 “extreme” risks, including large scanning equipment outtages continuing. 
• And it only had a “low assurance” than several different risks were being addressed by the Trust, including making sure that the Trust’s buildings and estate were safe for patients and staff.

 BAF and CRR Nov p90

• 15,844 patient safety incidents were reported to the National Reporting and Learning System (NRLS) as incidents that are “directly” related to estates and facilities services in 2018/19. These are patient safety incidents directly related to estates and facilities services. 
• 4,810 clinical service incidents were caused by estates and infrastructure failures in 2018/19
• 34 people were injured as a result of fires in 2018/19, and 1,541 fires were recorded. 

NHS Digital Estates Return 2018 – 19 

https://digital.nhs.uk/data-and-information/publications/statistical/estates-returns-information-collection/england-2018-19

GPs warn of patient safety incidents caused by winter crisis in GP online survey

GP Online, November 19 

https://www.gponline.com/patient-safety-fears-vast-majority-gps-predict-nhs-winter-crisis/article/1666522

9 out of 10 hospital bosses warn that staffing pressures are impacting patient safety

Guardian, November 19

https://www.theguardian.com/society/2019/nov/19/nine-in-10-nhs-bosses-say-staffing-crisis-endangering-patients

Chief Inspector of Hospitals at CQC warns that the NHS has made little progress on patient safety

https://www.telegraph.co.uk/news/2019/10/02/little-progress-nhs-patient-safety-past-20-years-says-chief/

NHS Providers warn that lack of investment is putting patients at risk of harm

https://nhsproviders.org/news-blogs/news/more-than-160-nhs-leaders-say-a-lack-of-investment-is-putting-patients-at-risk-of-harm-at-their-nhs-trust