Neil Zammett writes
As I have been asked to present the
petition asking the Secretary of State to reconsider the decision to close
A&E and Maternity at King George to the Council I thought it would be useful
to review where progress on the plans has taken us.
A&E remains in a state of
flux. Two years on from the original decision and a year after
Andrew Lansley’s qualified support for closure we still have no firm plan or
date. BHRUT are working on an outline business case which was
supposed to have been agreed by their Board in August but was still under
preparation when a question was asked of the Chair at their September Board
meeting.
Snippets of information from Trust
meetings suggest that a revised bed forecast has identified 90 beds not included
in the Health4NEL plan and that 3rd quarter 2014 is the earliest very
provisional “guesstimate” of the date when A&E will be closed.
Given the further delays in the business case this has now probably
slipped into 2015.
Length of stay was identified in the
original plan as the key variable in closing A&E and to date some progress
has been made. This has released 70 of the 250 beds originally
identified for closure but clearly there is still a long way to go.
One of the problems is that emergency workload has increased and just
recently the Trust has experienced an increase in length of
stay.
This is partly due to a lack of
community beds a situation which the interim Chair of the Trust, George Wood,
sees as worsening in the winter months. News has just been
released that St George’s in Hornchurch; a large local community hospital may
close before the winter which will obviously increase the pressure on
Queen’s.
Without seeing and evaluating the new
business case, and the BHRUT interim Chair has promised that this will be a
public document, I cannot take a firm view but all the indications are that a
closure of the A&E at King George can be ruled out for at least the next two
years.
This reflects the views expressed not
just by the Save King George Campaign, but local GP’s and the Council as
well. In the longer term the picture is much less clear and would
depend on the Trust’s ability to maintain a reduction in length of stay and some
stabilisation in the number of admissions. We should remember that
the original proposed closure date was around the turn of the financial year
2012-13, next March or April at the same time as
Maternity.
In the case of Maternity a detailed
plan has just been published in the September Board papers of the cluster PCT,
East London and the City. An initial view shows that as expected a “cap” is
going to be placed on the number of deliveries around 8000 for BHRUT and that
new catchment areas are going to be defined for each unit. Unlike
A&E the planned closure date of the King George maternity unit is March
2013, in line with the original plan.
This will involve about 800-1000
births transferring from BHRUT to each of Whipps and Newham. In a
major change from the original plan however, an equivalent number of births will
transfer from Whipps to Homerton to make room for Redbridge women.
This is because of physical capacity
constraints at Whipps, a point raised by campaigners in the original
consultation. It should be noted that the detailed plan has yet to
be agreed by all of the trusts involved. The good news is that
the cap is temporary which would allow BHRUT to re-open King George as demand
increases.
Taking A&E and Maternity together
my initial reaction is one of considerable surprise. The underlying concept of
the initial plan was the link between the closure of A&E and Maternity- if
you close one; you have to close the other. Now Health Trusts are
effectively pursuing separate plans with Maternity to close in March 2013 and
A&E remaining open for an indefinite period. This totally
undermines the thinking behind the original plan.
Many of the original concerns
remain. The plan will still result in very large units with about
9000 deliveries at Queen’s, Newham and Whipps in the medium term.
Choice will obviously be reduced
because women will not be able to opt for the popular King George unit and
perhaps most significant of all; we still have no workforce plan for
midwives. It is important to realise that we are taking not just
one but several major steps at the same time. The average size of a unit in
London is around 4500 deliveries and only a tiny proportion of women have
midwife led deliveries as opposed to the 40% planned. We have no
experience of recruiting to or managing units with 9000
deliveries.
There is also the problem that the
original plan only looked five years ahead and thus understated the impact of
population change. There is currently no provision for growth beyond 2015-16
which could be around 7000 additional deliveries per annum in East London, the
size of a large maternity unit.
There are however some fresh
concerns. The new plan is more complex and is being implemented at
high speed. Ensuring that all the units involved can manage this
pace of change brings new risks and in particular the day to day management of
capacity issues. When recording improvements a Queen’s CQC were
particularly keen that adequate time should be given to ensure that improvements
were sustainable. In my view the new plan does not do
this.
There is a risk that significant
numbers of women booked to one unit will have to be re-directed to another at
short notice. Underlying this is the issue of choice for
women. The original work of Health4NEL showed that women have a
very good conceptual grasp of the choices they should have but that the “system”
prevents them from exercising these choices in practice. Although
the new plan does mention choice it also recognises that women may have to
travel further to exercise this and does not address the relationship between
capacity and choices of location and mode of delivery.
There is also the vexed question of
consultation. As the decision is not to be made formally by East
London and the City PCT until January 2013 there is enough time for
this. Because the “caps” are temporary they
would not qualify for formal consultation under the regulations.
However, given that the catchment area changes are a package and the
Homerton proposal is new I would argue that the whole should be subject to
formal consultation.
In summary, the cluster PCT has made
significant changes to the original agreed proposal of which the three most
important are:
1.
Postponing
the closure of A&E at King George for at least two years from now to an
unspecified date in the future.
2.
Changing
the Whipps Cross and Homerton catchment areas for maternity to affect large
numbers of women in Waltham Forest.
3.
“Uncoupling” Maternity and A&E which undermines the original
logic of the plan to close Maternity.
I suppose the postponement of the
A&E closure could be seen as a victory for the campaign but I remain very
fearful about the future of Maternity and issues around long term capacity and
recruitment. What seems to me to be missing here is a sense of
strategy, taking a sensible look at the long term and balancing demand,
investment and income.
I guess I am talking abut
vision.
For all these reasons it is a good
time for a review of the original decision by the new Secretary of
State.
