Public Consultation Event - Grantham

I know of two people who have had to have ‘unplanned’ emergency surgery at Grantham Hospital - hip and wrist. Both received excellent care. If they had been taken to Boston or Lincoln, what guarantee can you give that they would receive the same level and quality of care?

We are pleased to hear this. The services at Boston and Lincoln will continue to deliver the excellent care for unplanned orthopedics if the proposals are taken forward as demonstrated throughout the pilot.  

What are the EMAS response times?

The national NHSE ambulance programme standards for all English services (x10) are:

• Category 1 - This reflects a time critical and life-threatening emergency requiring immediate intervention, to which ambulance services aim to respond within an average time of seven minutes, and at least 9 times out of 10 within 15 minutes. Such emergencies include cardiac arrest (heart stops) or respiratory arrest (the patient stops breathing), and airway obstructions.
• Category 2 - This reflects a potentially serious condition that may require rapid assessment, urgent on-scene clinical intervention and treatment and / or urgent transport and include probable heart attacks, strokes, and major burns. Ambulance services aim to respond to these calls within an average time of 18 minutes, and at least 9 times out of 10 within 40 minutes.
• Category 3 - This reflects an urgent problem which is not immediately life-threatening, but which requires assessment, and may need treatment and possible pain control. In some instances, ambulance personnel may treat patients in their own home or refer them onward to an appropriate health care professional (HCP). Ambulance services aim to respond to calls of this nature within 120 minutes at least 9 times out of 10.​​​​​​​
• Category 4 – This reflects a non-urgent problem which requires a form of clinical assessment which can be completed either over the telephone or face to face. Ambulance services aim to provide clinical assessment within 180 minutes at least 9 times out of 10.

EMAS’ performance can be found here: https://www.emas.nhs.uk/about-us/trust-board/next-board-meeting/   

How are EMAS going to cope if people are having to go to Lincoln County Hospital?

• As with all ambulance providers, EMAS runs a ‘stacking’ system which means that their crews are re-allocated across the county in accordance with demand and need
• There are significant benefits for EMAS when working with a service which can safely receive patients immediately upon arrival. The temporary COVID change to the stroke service in the county means that EMAS can take suspected stroke patients immediately to the stroke department at Lincoln County Hospital (bypassing A&E), and hand over the patient safely and quickly, allowing them to get back on the road. This reduces the pressure on the ambulance service.

What care is given at an Urgent Treatment Centre?

The scope of an Urgent Treatment Centre (UTC) includes both minor illnesses and minor injuries. A UTC will assess and treat patients who have a minor illness or injury that require same day urgent care treatment by a Health Care professional in the community. The model proposed at Grantham is an ‘enhanced’ service offering greater than a standard UTC for example it will be able to manipulate some fractures e.g., wrist fixtures, have access to x-ray, blood testing and CT and treat more complex patients that may require regular observations or need admission into an inpatient bed. The majority of UTC are GP led where the proposed Centre in Grantham will also have consultant support.

This means that the vast majority (estimated to be around 97%) of patients that were seen at Grantham and District Hospital’s A&E (before the temporary change) would be treated by the proposed 24/7 Urgent Treatment Centre (UTC).

​​​​​​​​​​​​​With the nearest A&E for me now 45-60 minutes away, if I had another heart attack, what chance would I have to survive it?

It is widely clinically accepted that anyone suffering an injury or illness as acute as a heart attack is best treated by specialists, at a place with the necessary equipment and co-located services to give the best chance of survival and recovery. Grantham and District Hospital has had an exclusion criterion in place since 2008 which has meant that patients suffering a suspected heart attack are taken to other centers.  If a member of the public presented at the UTC with a suspected heart attack the staff in the centre do have the capability to manage the patient pending transfer to more specialist appropriate unit (such as the Lincolnshire Heart Centre).

 National and International evidence demonstrates that patients taken to a dedicated cardiac centre have improved outcomes, reduced mortality than patients taken to local smaller units.

What thought has been given to the extra homes to be built in Grantham? There are nearly 8000 new homes planned in the next 20 years.

We have taken into account the expected growth in population in Grantham town and believe that our emerging option of a UTC would meet this demand.  We are part of the ‘One Public Estate’ initiative with many partners involved in the development planning around Grantham and are therefore fully aware of the future potential growth in housing, which has been incorporated into our planning work.

We understand the type of injuries and illnesses that have been presented at Grantham for many years now and believe these proposals provide the most sustainable and appropriate urgent and emergency care service for Grantham now and in the future.

What is going to be done regarding seeing a GP at their surgery? We already see A&E being used by people that cannot get a face-to-face consultation with their doctor. The UTC will inevitably become used as such. So, before changes are made to A&E/UTC services, shouldn’t the GP surgery issue be addressed first?

Whilst GP access does not form part of this consultation process, we know that there is significant work being undertaken by colleagues across the NHS system to increase access to primary care appointments. 

What is the outcome if the UTC is swamped by patients who are unable to obtain an appointment with their GP?

All our urgent and emergency settings ‘stream’ patients upon arrival to ensure appropriate pathways are adopted (wherever possible). This includes inappropriately presenting patients, who are advised they may/ will be best cared for by seeing their GP at the next available appointment. Where patients wish to pursue the UTC route, they are prioritized accordingly so patients with lower acuity complaints will inevitably end up waiting longer than those who need a specialist urgently i.e. A patient in significant need will always receive their care as a priority

What are the exact differences between a UTC and an A&E? Can you give an example or cases of each?

Common terminology, although not formally defined by NHS England, are ‘Type 1 A&E department’ (major A&E) providing a consultant-led 24-hour service with full resuscitation facilities, a ‘Type 2’ (single specialty A&E service such as ophthalmology, dentistry) and ‘Type 3’ (other A&E / minor injury / walk in centre / urgent care centre treating minor injuries and illnesses).

You can go to an urgent treatment centre (UTC) if you need urgent medical attention, but it's not a life-threatening situation.

Conditions that can be treated at an urgent treatment centre include:

• sprains and strains
• suspected broken limbs and fractures
• minor head injuries
• cuts and grazes
• bites and stings
• minor scalds and burns
• ear and throat infections
• skin infections and rashes
• eye problems
• coughs and colds
• high temperature in child and adults
• stomach pain
• being sick (vomiting) and diarrhea
• emergency contraception

Accident and Emergency (A&E)

Accident and Emergency is where you go when a condition is life-threatening. A&E Departments have more in-depth analysis and diagnostic testing. They contain experienced specialists, like, cardiologists for heart attacks and orthopedic surgeons for complex bone fractures.

An A&E department deals with genuine life-threatening emergencies, such as:

• loss of consciousness
• acute confused state and fits that are not stopping​​​​​​​
• chest pain
• breathing difficulties
• severe bleeding that cannot be stopped
• severe allergic reactions
• severe burns or scalds​​​​​​​
• stroke
• major trauma such as a road traffic accident

A UTC has the staff to stabilize and support people who need a Level 1 A&E whilst organizing for that patient to get there. However as outlined in a response to a previous question the proposed UTC at Grantham would offer a greater level of service offer than the core national specification.

Why travel to Lincoln for treatment to then travel back to Grantham for acute care?

Being seen by the right clinician in the right place will greatly improve patient outcomes. The vast majority of people in Grantham would continue to be seen safely at Grantham UTC under these proposals. Patients should only go to a Level 1 A&E department if their condition requires them to need specialist care not provided at Grantham (services). After an initial acute episode, it is clinically proven to be more beneficial for patients to return home, or as close to home as possible for their longer-term recovery care. This is why our proposals for acute medical beds retain the service at Grantham.

Consultant oversight - what does it meant at the UTC?

The national specification for a UTC does not include a consultant subversion with Middle Grade doctors on the rote, however the UEC proposal for Grantham does. This means that there is a consultant physically in the UTC Monday to Friday 8-4.

Will there still be middle grade doctors, and will it be 24/7 walk-in permanently?

At the UTC there will be middle grade doctors and it will be open 24/7 for walk in patients.

Is anything else changing – fracture clinic. Do we lose anything else?

No, we are only proposing the changes we are consulting on.​​​​​​​​​​​​​​​​​​​​

Will there be a reduction or increase in acute beds at Grantham?

How many acute beds will there be at Grantham Hospital?

There is no planned reduction to the number of acute medicine beds under the proposal. The Acute Medicine change proposals being consulted upon relate to the way care is delivered on the Acute Medicine wards at Grantham and District Hospital.  The change proposal focuses on retaining this service, retaining acute specialists, and strengthening it through greater integration with community and primary care providers.

How will you be able to manage the expensive logistical challenge of delivering acute care in the community?

The proposal is not for a community provider to provide acute services – the proposal is to establish a partnership model. Our preferred proposal for change is to establish integrated community/acute medical beds at Grantham and District Hospital, in place of the current acute medical beds. The integrated community/acute medical beds would be delivered through a partnership model between a community health care provider and United Lincolnshire Hospitals NHS Trust. The care of patients would still be led by consultants (senior doctors) and their team of doctors, practitioners, therapists, and nursing staff. It is anticipated this change would affect around 10% of those patients currently receiving care in the acute medical beds at Grantham and District Hospital This is equivalent to 1 patient a day, on average. These patients would receive care at an alternative hospital as they would need to go to a more specialist acute unit given severity of needs with the right skills and facilities to ensure the best possible outcome.

However, 90% of the current patients in the acute med beds at Grantham would continue to be treated in the integrated acute/community beds We envisage the number of medical beds required at Grantham in this new model will not be reduced.

Acute medical beds provision would continue to be delivered at Grantham and District Hospital through a high-quality service delivered in a sustainable way for the long term – including a more sustainable medical and nursing workforce.

As part of the integrated community/acute medical beds model, will there be close working with adult social care services provided by the county council?

Creating a multi-disciplinary, integrated service at Grantham will enable us to provide a centre of excellence which supports improved community-based management of long-term health conditions and shorter stays in hospital beds, particularly for the frail/elderly.  As a multi-disciplinary team, the service will be led by specialist consultants and delivered by medical nurses and therapy teams. The integrated community/acute medicine teams would be responsible for liaising with social services where required to ensure the appropriate care packages are put in place. This partnership work is already occurring daily across the county and will continue to be progressed and developed.

Do you feel confident that stroke victims can be treated within the Golden Hour? Also, how quick must you treat acute heart failure to make that difference?

The Golden Hour is a generic term to describe treatments that must be delivered within a short timeframe. It doesn’t always refer to specifically an hour. The treatment that must be delivered within a short timeframe relevant to stroke is thrombolysis, and the timeframe for delivery is recognised as 4.5 hours. There is strong evidence that investigations and interventions for stroke, such as brain scanning and thrombolysis, are best delivered as part of a 24/7 networked service that includes comprehensive and acute stroke centres of a sufficient size to ensure expertise, efficiency, and a sustainable workforce.  Networked configurations with hyper-acute stroke units (HASUs) have led to better patient outcomes, including a 5% relative reduction in mortality at 90 days and reduced length of stay.

Our data analysis, and the learnings we have from the temporary changes to the stroke service due to COVID (centralized at Lincoln County Hospital (LCH)) inform us that we can deliver this treatment within this timeframe to residents from across the county. We are also confident that the improvements to the complete care journey this proposal enables (rehabilitation etc.) will make a significant different to the quality of life of 100% of stroke survivors in the county.

Acute heart failure has a much more restricted window in which to treat a patient (People who have had a heart attack need to be treated within two hours to make primary angioplasty effective and to avoid further damage to the heart muscle). Similarly, to the stroke proposal, the Lincolnshire Heart Centre operates from LCH, and requires patients from across the county to travel there to commence a more time sensitive treatment programme. The centre achieves this successfully and is consistently in the top 10 performing centres in the country.

Is the vital stroke medication administered in the ambulance?

No. However, we work closely and well with our EMAS colleagues to ensure that as many of the preparatory care is provided on this journey. This is working well, with strong communication between the teams resulting in vital time being saved upon arrival.

Can you categorically state that the UTC will treat an emergency stroke victim?

Since 2008 suspected stroke patients have not been taken to Grantham Hospital and this will not change if the proposal was implemented.  National and International best practice shows that stroke patients have better outcomes if they receive their care from specialist stroke units, and in Lincolnshire, when conveyed by ambulance, they are taken straight to the team. However, if a patient presented at Grantham Hospital now or if the UTC proposal was taken forward the staff will have capability to stabilize pending onward referral to specialist unit.

Why move stroke to Lincoln County from Pilgrim, Boston?

There are a number of reasons why LCH is proposed rather than Pilgrim Hospital, Boston.

• There is strong evidence that investigations and interventions for stroke, such as brain scanning and thrombolysis, are best delivered as part of a 24/7 networked service that includes comprehensive and acute stroke Centres of a sufficient size to ensure expertise, efficiency, and a sustainable workforce.  Networked configurations with hyper-acute stroke units (HASUs) have led to better patient outcomes, including a 5% relative reduction in mortality at 90 days and reduced length of stay
• Lincoln County Hospital admits around 670 stroke patients a year and Pilgrim Hospital, Boston around 470 stroke patients a year. There are more strokes occurring in the vicinity of LCH, and we know that more people would be displaced (have to travel further) if the proposal was for Boston
• We have learnt that the majority of our staff would prefer to be based in Lincoln, so staffing the proposal would be a risk if it was for Boston
• If we moved stroke services to Lincoln, patients would also benefit from the being on the same site as the highly successful heart Centre which enables increased access to vital diagnostics. Co-location of services can have a significant benefit to patients’ care and Lincoln has more complimentary services.
• In the instance that a patient presented at a hyper acute stroke Centre in Lincoln and it was discovered that mechanical thrombectomy was required, the transfer time to the nearest Centre in Nottingham is shorter (compared to Boston)

What are the ULHT doing to train and keep their staff?

Across the UK, there is a severe shortage of healthcare staff, particularly in the services we are consulting about. Staff shortages have meant that our teams have had to be on-call more often or work extra hours across two hospital sites in order to keep patients safe. We have also had to recruit temporary staff who are not as familiar with our hospitals and have therefore needed additional support.

By offering a more attractive workplace, with a more sustainable future, we believe we will be able to recruit more staff into the services to alleviate some of the current staffing pressures.

By establishing a Centre of excellence on one site and investing in the proposed changes, we can best utilise the skills of our teams and make services more sustainable for the future. A Centre of excellence means our staff see more patients, which helps to maintain staff skills and ensures their access to the most up to date training.  This in turn will increase staff retention and make ULHT a more attractive option for junior doctors and nurses.

In the meantime, ULHT is also focusing on further efforts to recruit and retain staff, including a successful international nurse recruitment campaign and a focus on supporting existing staff through wellbeing support and a new flexible working policy.

Why not rotate staff over different sites in order to allow them to treat enough patients and keep up their skills?

At present, in order to move staff to support services at so many sites across the county, we must use their clinical time for travel time, reducing the number of patients they can see each shift. This is not good use of public funds, particularly when there is a national shortage of staff.

We also know that, in the instance of stroke to which this question applies, working in Boston has less appeal to staff than in Lincoln. This is evidenced in our previous attempts to rotate staff in just this way, as a number of the refused to work in Boston and moved out of Lincolnshire altogether.

Is this the same proposal as October 2019? About 18 of us took part in a workshop. (I support the proposal). 

Broadly yes, with the exception that the proposal for urgent and emergency care at Grantham and District Hospital has been altered to reflect feedback from the public to be available 24/7 and with walk in access.

How is Lincoln going to cope and they can’t cope now?

With the change of model and services transferring to other sites i.e., pediatric, maternity, stroke, compound fractures – can Lincoln and Boston cope with the additional demand?

Re orthopedics: During the pilot for Orthopedics which the current proposal is based on, waiting times and on the day cancellations were considerably reduced.  There is no evidence to suggest that this trend would not continue if the proposal were to go ahead. 

Re acute medical beds: The proposal for the of acute medical/community beds model at Grantham and District Hospital is believed would further alleviate the burden on acute wards at Pilgrim Hospital, Boston, and Lincoln County Hospital. 

Re stroke services: During COVID, stroke services at Lincoln and Boston were largely centered at Lincoln to help better manage demand and cope with staffing levels. We therefore know that this proposal will help the service to cope and there is additional capacity planned as part of the proposal.

Re urgent and emergency care: the national pressures seen in hospitals at present would not be affected by the proposals. We believe that stabilizing UEC services at Grantham will enable more care to be delivered in a more appropriate and manageable way across the whole of Lincolnshire. It would also provide 24/7 access to the local population thus reducing the pressure on the other sites.

Why no suggestion of new buildings at site of Prince William of Gloucester Barracks?

The ambition is to redevelop the Grantham Hospital site, however that requires significant capital funding to be delivered. There has been no formal discussion of repurposing Grantham and District Hospital on the barracks site.

Why have the critical care services needed to support an A&E in Grantham been allowed to run down so they are no longer available?

It is the CCG’s responsibility to commission the appropriate services for the county in its entirety with the funding available to it. Changes to services as this happens are inevitable and always focused on providing the best deliverable patient outcomes.