What Can We Learn from England’s Top-Rated Trust

Northumbria proves that slashing waiting times isn’t just political lip service

Last week, The Times devoted a full feature to Northumbria Healthcare NHS Foundation Trust under the headline: “Inside the best NHS trust in England – how does it do it?” In a time where all we seem to see and hear about the NHS is negativity, such praise made us sit back and dig further. Northumbria hospitals provide proof that tackling waiting times is not just a pipe dream that is repeated before every political election.

While the national average for the four-hour A&E target has slipped to 75%, Northumbria manages 91% and it has the lowest 18 week elective time of any non-specialist NHS hospital in the country.

Behind The Numbers

Take the flagship site at Cramlington. Here, only a quarter of patients end up in the traditional A&E waiting room.

Northumbria prioritises immediate assessment on arrival, with patients being triaged quickly. We have all seen the low acuity presentations at the front door of the emergency department and whilst you can try your best to educate, human nature tells us that these types of visits will still happen when health is in the question.

A clinician at the door to redirect these low acuity presentations to a pharmacy, GP, or other community services is key to preserving space and time. As Dr Sasidharan, one of the A&E consultants, explains, many people come to casualty because it’s the only 24/7 door into the system — even for minor complaints like a cut finger. By intercepting these cases early, staff preserve emergency resources for those who truly need them.

United Accident and Emergency

But the real masterstroke lies in how Northumbria re-engineered its entire system of care. In 2015, the curtain was unveiled on the famous NSECH (Northumbria Speciality Emergency Care Hospital) which was the result of Northumbria consolidating three district general A&E departments into a single £75 million specialist emergency hospital at Cramlington.

Northumbria decided to break care down into what it termed ‘hot’ and ‘cold’ care. This site focuses exclusively on ‘hot’ care: major emergencies, trauma, and acute medicine. Routine elective surgery and planned care were shifted to the trust’s three general hospitals, ring-fenced from the unpredictable pressures of winter.

That separation of hot and cold streams has been transformative. Seasonal surges of flu, Covid, norovirus no longer derail elective lists as they spread through the wards. Surgeons can keep operating while acute physicians absorb the winter wave. The result is that Northumbria now posts the lowest waiting times of any non-specialist NHS trust.

But is this model as simple as it sounds? Can it be applied to all regions with different geographical factors and travel times? Integrating three separate hospitals into one united centre may work in rural areas, but it may be a logistical nightmare in more densely populated urban areas where it takes you half an hour to drive from one end of your road to the other as it is. Having said that, there is a sizeable population that would trade shorter A&E waiting times for a longer pre-hospital drive.

Organ Donation Ethics: The Dead Can’t Suffer, But Families Do

Right now, thousands of people are waiting for an organ transplant, yet many will never receive the call that could save them. In most countries, most potential donors haven’t registered their wishes, leaving families to decide.

Many see themselves as the “heirs of the body,” believing their authority outweighs the deceased’s because they must not only carry the grief of loss but also the lifelong burden of the decision.

This raises a deep ethical tension: should the wishes of the dead really outrank the suffering of the living? In the UK, where autonomy is almost sacred, many instinctively answer yes. But once a person has died, they cannot experience harm or benefit. Families, by contrast, must endure guilt, doubt, and the impact on their grieving process.

It may therefore be ethically stronger to prioritise those still alive. But hang on, couldn’t we use this exact ‘suffering-calculation’ argument when discussing the waiting organ recipient and their family who suffer immensely on a daily basis awaiting a phone call that could change their lives.

Families also point out that many donor registrations are made casually, ticked at 18 without much thought, whereas they, in the moment, hold the cultural, emotional, and contextual knowledge of what feels right.

Yet, against this stands the reality: a refusal can mean another life lost. Research shows that donor families often adopt a utilitarian view, seeing organs as “worthless” after death, though the paper suggests that many still draw a line at symbolic organs like the heart, eyes, or skin.

There is no single answer to this debate. It also ties into the difference between soft and hard opt-out systems. In a soft opt-out system, the family can refuse donation. In a hard opt-out system, only the individual’s choice counts, if they didn’t opt out while alive, they are considered a donor.

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Too Many Waiting? How Loopholes Help Share the Load

How workloads are shifted between specialities

When the waiting room is full and waiting list is long, sometimes quick solutions are needed. And one shortcut out of this clinical jam is shifting the load onto other specialities. This week, we wanted to explore what some of the commonly encountered shortcuts and loopholes look like in our profession, from the viewpoint of certain specialties.

So what do we mean by loopholes? These are strategic referrals used to shift workload or grey areas where hospital rules don’t clearly dictate who takes responsibility.

The View from ITU

Not everyone has worked in intensive care, but there really shouldn’t be much room for doctors working in our health service, especially in secondary care, who don’t know the roles and responsibilities of the intensive care department.

Difficult discussions surrounding the ceiling of care for unwell patients are an everyday part of hospital medicine. The ITU team should not be expected to carry that burden because the referring specialities don’t have the energy, interest or bravery to have robust ceiling of care discussions with a patient and their relatives.

Then there’s the cardinal sin of prematurely guaranteeing a patient an ITU bed and then painting Intensive Care as the solution for a patient who has twenty-two active issues and a highly uncertain recovery. It’s a sin because it forces the ITU team to be roadblock or the care-deniers.

Direct Referrals to Specialties

We covered the overflowing nature of our emergency departments in a recent piece. What this can sometimes lead to is an ENT SHO being dragged from corner to corner receiving direct referrals from A&E triage for patients that haven’t been systematically assessed by an A&E doctor.

This of course, brings the risks that systemic issues may be missed, not to mention that ED doctors are also perfectly capable of confidently treating common issues like painful tonsillitis or inserting a rapid rhino for an epistaxis.

There are, of course, certain scenarios where direct referrals may be appropriate such as in the event of post-op complications, and if this where the line for direct referrals is drawn, there isn’t too much of an issue.

However, the reality is that the line for appropriate ‘direct to specialty’ referrals is often blurred, and the grey-area often grows when an desperate emergency department is in need of some space.

Perhaps the antidote lies in transparency. If specialties were called with a message along the lines of, “This may well be a straightforward and uncomplicated nasty tonsillitis case that our ED doctors could handle, but given how overwhelmed the department is right now, we were hoping you might be able to take a look,” then a sense of camaraderie and mutual respect might make such referrals easier to accept, and maybe, even, help ease the age-old tension between specialties.

“I’d argue there’s no better feeling in my speciality than telling a patient that the surgery went well”

“I am very much convinced that many members of this profession either don’t understand or completely underestimate the legal difficulties that come with the implementation of UK graduate prioritisation”

“ST7 Cardio reg here. I often sit there and think whether I would go through all this pathway again from medical school to my current position if it was guaranteed i’d pass through the hurdles at the times I did. To be perfectly honest, i’m not too sure. I’m reminded of all the tough shifts that have come and gone, but the idea of starting over, fixing old mistakes and even making new ones makes the decision much harder”

“For any respiratory doctors here, it is common for your COPD patients to have such difficult home circumstances that you end of seeing the same familiar faces admitted with COPD problems/exacerbations over multiple years with unmet needs before they eventually die”

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Some things to review when you’re off the ward…

There is a general belief in Upper GI bleeding that the sooner an OGD is done, the better. This claim is dubious. Mortality in acute upper GI bleeding, for non-variceal causes, is lowest if scoped 12-24 hours after the bleed. See Lau et al here.

There has been plenty of debate over mucoactive agents (Meds that help clear thick mucus from airways to you and me) use. A new RCT by the New England Journal of Medicine compared hypertonic saline with carbocisteine with the measured outcome being pulmonary exacerbations. The results? Carbocisteine had no effect compared to control. Hypertonic saline results suggested fewer exacerbations but the results were non-significant. Adverse events were also similar across both groups and considered safe.

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‘Doctor Decision-Fatigue’… Does It Even Exist?

You hand over the bleep, wrestle your way into your jacket, and glide down the corridor toward freedom. Minutes later, you’re home, only to be ambushed at the door with: “Rigatoni or fusilli tonight?” Even a question of such triviality from a loved one making you dinner feels like a challenge for your drained brain. Naturally, you blame it on decision fatigue.

Most of us have heard this idea at some points in our training. It is the idea that making repeated medical decisions is so mentally demanding that it eventually leads to deteriorated decision quality over time. This is the intuition we all have… but does it stack up with the data?

Well, a paper in Nature (yes, the high impact factor one), decided to test this out by using massive real-world data sets. They looked at thousands of actual medical decisions and found no difference to suggest that decision making ability declined on fatigue levels.

The authors of the paper suggest that whilst ‘actual decisions’ don’t measurably change (e.g. nurses don’t make greater errors later in the shift), their subjective experience may do so. They may feel more tired, drained or mentally fatigued, even if their choices stay consistent. It could also lead to other non-decision outcomes such as more stress or frustration.

The takeaway is that decision fatigue may be more about how we experience work, rather than how the decisions actually play out.