Birmingham Heartlands Hospital

On this page

• Overview
• Person-centred Care
• Care provision, Integration and continuity
• Providing Information
• Listening to and involving people
• Equity in access
• Equity in experiences and outcomes
• Planning for the future

We rated responsive as requires improvement. We looked for evidence that the service met people's needs. At our last assessment we rated this key question requires improvement. At this assessment, the rating remained requires improvement. The service was in breach of the legal regulations relating to safe care and treatment due to long waits, crowding and lack of flow in the department. However, there were some good areas in this key question including good person-centred care and learning from complaints.

We have not awarded this service a score for Responsive.

Find out about when we will not publish a key question score and what we look at when we assess Responsive.

We did not look at Person-centred Care during this assessment. The score for this quality statement is based on the previous rating for Responsive.

We did not look at Care provision, Integration and continuity during this assessment. The score for this quality statement is based on the previous rating for Responsive.

The service did not always supply people with appropriate, accurate and up-to-date information in formats tailored to individual needs. Patients did not always have access to interpreters and family members acted for them.

Not all patients had good information about what was happening to them. Patients and relatives to whom we spoke usually knew what was happening to them and about the plan for their care and treatment. However, some patients and relatives did not know where they were going next, what their assessment and treatment plan was and why they were waiting. Some people were confused by the idea of waiting for a bed and some were frustrated as to why other patients were transferred before them. The CQC annual Urgent and Emergency Care Survey 2024 indicated that the department was worse than expected for people being told what would happen next.

The hospital’s patient experience work had noted that people were sometimes frustrated by a lack of information about waiting times and their journey through the department. The department had responded with large wall posters about this in the ambulatory area and was introducing television screens with waiting time information in the 6 most common languages used by people who attended the department.

Senior staff told us that signage was a problem across the site, and we saw this was something raised by patients in the recent Patient Experience Report. While the entrance to the adult emergency department was clearly marked some people found it difficult to identify the separate children’s entrance which involved walking around the back of the building. We were told and saw evidence that there was a hospital wide project to improve this to the current NHS “wayfinding” standard.

There was not a good use of translation or interpretation services. The local population had a high proportion of people who were either non-English speaking or for whom English was a second language. While the hospital provided an interpreter service, the take up of this in the emergency department was very low; we saw data that this was less than 1 interaction a day. The service attributed this to crowding and lack of space for the staff members and interpretive equipment. Several patients to whom we spoke had limited use of English and were accompanied by family members who said they acted as an interpreter. This was not good practice and ideally these patients should be provided with an interpretation service.

The department’s risk register noted that the use of multiple computer systems which did not always exchange information resulted in duplicated data entry leading to wasted time, errors and a lack of continuity of records. This was being addressed though a project group to move onto a common approach. It was also noted that when there were failures of systems there were not always enough “packs” available to support temporary paper-based working.

Patient records were held on secure systems which met relevant data protection and information processing legislation. Access to electronic patient records was password protected with a secure login.

The service made it easy for people to share feedback and ideas, or raise complaints about their care, treatment and support. Staff involved people in decisions about their care and told them what had changed as a result.

There was information in the department about how to complain but most people, when asked said they would complain to a manager or member of staff.

The service encouraged people to comment on their experience and when necessary, complain. There was a good performance on response to complaints with all having been responded to in the required time in the period we reviewed of December 2024 to February 2025.

Staff knew about the complaints system and how to support people to complain. Most staff said they would not dissuade people from complaining, but they would try and find out what was wrong and to fix it there and then.

Staff were trained in how to investigate and respond to complaints. We looked at a sample of complaint responses and they had been dealt with in an appropriate and, when necessary, diplomatic manner. There was evidence that the issues important to the complainants had been addressed and where failings identified steps taken prevent recurrence, all of which was explained in the response letters.

The department fed learning from audits, incidents and complaints into its management and clinical governance structures. When complaints identified training or performance issues they were taken seriously and followed up with individual or groups of staff. Staff told us most complaints were about the physical environment and waiting times and this was borne out by the complaints we saw, and the information provided to us by patients.

The service could not make sure that people could access the care, support and treatment they needed when they needed it. People could attend the service when they needed it but were often subject to long waits. People did not receive timely care and treatment in line with national performance standards. We acknowledge at the time of our assessment visit, compliance with national standards around waiting times was a significant concern and an issue across most emergency departments and had been for many years.

The demand on the department far exceeded the original designed capacity. While the expansions, reconfigurations and changes to processes had reduced risk and improved flow, they could not address the underlying root causes of system pressures in the local health economy. Because of a lack of available beds in the hospital and social care provision, there was a restriction of flow out of the department meaning that there were long waits for patients to leave the department. Despite constant efforts, this affected the department's ability to assess and treat newly arrived patients and led to crowding which made the department less efficient, effective and safe. In turn the department had difficulty accepting new patients and, in the case of those arriving by ambulance, this meant patients could not be handed over and had to be cared for on the ambulances. Because these ambulances and crews could not get back on the road this resulted in delays in response to calls and a risk to people in the community.

There were processes to manage and promote the flow of patients through the department, to discharge home or admit patients to the hospital, but they were not always working effectively. There were long delays in accessing care and national standards around waiting times for emergency departments were not met. At the time of our assessment visit the department was under less than usual pressure because of a lower demand and better bed availability in the hospital. However, it was operating at capacity and there were times when individual areas, such as resuscitation were full, and steps had to be taken to move patients to accommodate those who were more unwell.

During our visit we saw few patients being cared for in corridors or other spaces, and there were no more than 5 ambulances outside at any time. However, we knew from reports we received prior to our inspection as well as documents we were sent by the trust in response to our information requests there were often significant delays to the assessment and treatment of patients. This was particularly in handovers of patients from ambulances. Aside from the reports we saw, all staff, and particularly leaders and managers, were candid about the pressures the department frequently came under and the effects this had on patients and staff.

On the days of our visit, while the department was busy, senior staff characterised it as having "flow" meaning that the processes worked, and patients moved through the department. Asked why, they said that it was down to a combination of factors. These included good discharge overnight from both the department and the rest of the hospital. There was low acuity on the medical wards meaning that they could accept patients through the hospital's `push model', and there was lower demand for ambulances in the community.

There were other services designed to alleviate the pressure in the emergency department. Aside from the majors and minors areas within the department there was a minor injuries clinic, as well as medical, surgical and gynaecological assessment units. There was a Same Day Emergency Care (SDEC) facility located close to the department for medical patients. It had its own staff and effectively reduced pressure on the department by taking up 100 patients a day who were directed there by medical navigators based in the emergency department. Some patients who were assessed as frail could be directed to the SDEC service where they received the support they needed. Senior staff were keen to see a similar service for other specialities, particularly surgery.

The service had a well-defined and managed ambulatory pathway that started at the entrance to the department where all patients were met by a `streaming' or `navigator' nurse. Based on an initial conversation, before they entered the building, patients were streamed to a suitable area of the hospital or diverted to other providers such as their own GP or the local urgent care provider. Several staff and managers told us how effective this approach was in ensuring only patients who needed their services were brought into the emergency department. When observing this process, we saw examples where patients were taken straight through for tests, and where an immediate medical opinion was sought. In 1 case a patient was identified as being seriously injured, taken out of the queue and through to the majors area. We also saw people directed to other providers and services and given support and guidance to do this.

All ambulances and ambulatory patients were assessed, and a Manchester triage score applied which indicated the priority for assessment and time critical interventions. This gave an immediate indication of the level of risk posed to an individual patient.

There were clear policies for recognising when the department was coming under pressure, and there were mechanisms with which to respond. These were enacted and enabled through standard operating procedures. These included "Emergency Department Rapid Assessment Triage and Treatment," "Enabling Emergency Department Flow" and "Emergency Departments Non Cubicle Care of Majors Patients." There was also a full capacity protocol, and all these were aligned with the standard NHS Operational Pressure Escalation Level (OPEL) framework.

The full capacity protocol used a matrix of risk assessment based on the OPEL framework. There were action cards for key stakeholders that indicated risk and assigned responsibility. Site meetings were initiated in consideration of the OPEL scores and system partners were involved as necessary with escalation to system responses and oversight by the integrated care board as the situation worsened.

The hospital was using a modified version of a patient flow model developed at a hospital in Bristol to help to relieve pressure on the emergency department, and to share the risk across specialities. This was known as the `push model' where patients were sent up from the emergency department to the wards before a bed was available. The patient had to be low risk and have a low early warning score.

The promotion of flow in the department was a priority and this was enabled through flow co-ordinators, 1 for the ambulatory area and 1 for the majors area and these worked with the senior medical and nursing staff responsible for those areas. These co-ordinators identified barriers to individual patients leaving the department including the chasing of referrals to specialities that had not been addressed.

Due to factors described here, the department was not treating, discharging or admitting people to wards within the standards required by the NHS constitution — known as the 4-hour standard. The standard was to treat, discharge or admit 95% of people within 4 hours. There was a temporary change to the standard by NHS England following the COVID-19 pandemic and the recognised pressure on many accident and emergency departments. This reduced the standard to 78% of patients meeting the 4-hour threshold. However, the department achieved 61.2% in February 2025, against an England average for all patient types of 73.5%. This had improved slightly from the previous February which just below 60%.

Although showing signs of beginning to improve, far too many patients were spending too long in the department. In published data for patients waiting more than 12 hours from a decision to admit them to a ward bed, 14% of patients fell into this category in February 2025. This was against the England average of 13%. This amounted to 1,435 patients being held for more than 12 hours. However, this was an improvement from the peak of January 2024 when 17% of patients waited more than 12 hours.

The capacity of the department was frequently exceeded. Numbers of patients above the bed and trolley capacity resulted in patients from the majors area being cared for in corridors. In the ambulatory area patients stood, sat on the floor, spilled into other adjacent areas of the hospital or were accommodated 2 to a cubicle.

Resuscitation patients regularly overspilled into the majors area and during our visit we saw conversations about which patients needed to be moved to accommodate ambulance pre-alerted patients coming to the resuscitation area.

Patients were sometimes treated on chairs in the ambulatory area and several members of staff told us that the seminar room had been used to seat patients receiving intravenous antibiotics.

Vulnerable patients did not always get responsive onward care or services. The department was often challenged to safely discharge patients who had been treated and were medically fit but were homeless or had escalated care needs and could not return to their home. While there were referral pathways for these people to be found a place, there was often no service overnight or at weekends and they needed to be accommodated in the department.

Similarly, patients who required a mental health bed were often accommodated in the department for several days before a suitable placement could be found. During our visit we saw how this meant a cubicle was tied up, staff were assigned to support them, and managers spent time liaising with other providers and commissioners to identify somewhere for them to go.

Parking space outside of the department for ambulances was limited and so they, with patients on board, were parked around the hospital which presented a risk should the patient's condition deteriorate.

We did not look at Equity in experiences and outcomes during this assessment. The score for this quality statement is based on the previous rating for Responsive.

We did not look at Planning for the future during this assessment. The score for this quality statement is based on the previous rating for Responsive.