Friday, September 28, 2012

NHS reply to earlier post

Andy Strickland Media Manager for ONEL writes

When writing about St George’s hospital in Hornchurch, you say: ‘If BHRUT were not planning to spend large sums of money on an unnecessary A&E extension at Queens it might have the money to keep the existing estate (i.e. at St George’s) up to standard.’

Just to clarify, St George’s is not a BHRUT hospital. The site is owned by NHS North East London and the City (NHS NELC) and services are provided by North East London Foundation Trust (NELFT), not BHRUT. So a bit unfair to criticise BHRUT on this one I’m sure you’ll agree. They aren’t involved in any of the decisions currently being taken about the bed-based services at the hospital or the longer term plan for the site as a whole.

Thursday, September 27, 2012

Can you help BBC?

The BBC is to do a piece on maternity closures per the below.

If you know some "concerned mums" who would be willing to talk on the radio about the plan to close maternity at KGH, please could you ask them to contact Madeline on the number below.

From: Madeleine Briggs <>
To: "''" <>
Date: Thursday, 27 September, 2012, 12:55

Hello Andy Walker,
I’m a producer at BBC Radio 5live, you may have received a mobile phone message from me.
Next Tuesday on Shelagh Fogarty’s programme we are taking an in-depth look at Maternity and as one strand we will be looking at the closure of units.
We would be keen to speak to a couple of people from your campaign…
Would you be able to help put me in touch with some concerned Mums etc
Madeleine Briggs
BBC Radio 5 live - Daytimes ( +44 (0)161 3356506
: 909 / 693 AM, Digital Radio, Digital TV, & online
twitter: @maddybriggs/@bbc5live

Tuesday, September 25, 2012

Extension & Maternity Mysteries

 Last night at a Council meeting I asked Dr Mike Gill, a senior BHRUT manager, about how many beds the proposed A&E extension at Queens was going to have in it. His reply was something along the lines about the size of the building being down to financial modelling which meant he could not be specific about the number of beds. Perhaps money, rather than clinical reasons, is driving what is going on at BHRUT. 
Later on, the same meeting was told that money was so tight a boiler could not be replaced at St Georges Hospital in Hornchurch which meant beds were going to have to be closed. If BHRUT were not planning to spend large sums of money on an unnecessary A&E extension at Queens it might have the money to keep the existing estate up to standard.  
Maybe the special council meeting on 22 October about KGH will write to Mr Hunt with this latest news. It is incomprehensible that BHRUT want to spend many millions on a new A&E building  at Queens to allow the closure of KGH A&E. Neil Zammett asked a question about whether the final decision on KGH maternity had been made yet and was told it had not been. It seems Clinical Commissioning Groups will have a say in the matter, which is contrary to the press reports indicating the final decision has been taken.

I have sent this post to BHRUT in case they want to comment.

Press links are below:

Friday, September 21, 2012

Redbridge to write to Mr Hunt

Last night Redbridge Council agreed to write to Mr Hunt, the Secretary of State for Health asking him to "review" the proposals to "reconfigure" A&E and Maternity at KGH. I have written to the Chief Executive and party leaders drawing their attention to press articles about what happens when a A&E is shut and the remaining A&E struggles to cope, in case they feel any of this information should be included in the letter to Mr Hunt.
 A quote from David Rose follows taken from the Mail about what happens when an A&E department is closed. He writes:
 "As emergency cases are forced to travel elsewhere, the number of patients waiting in those departments for longer than the official four-hour target before being seen has more than tripled."
 The article mentions a Sheffield university study which found ambulance travelling longer distances to an A&E led ‘an increased risk of death’. The article can be read in full here The conditions needing care quickly are "anaphylactic shock, choking, drowning or having an acute asthma attack" according to link here.

Dr Michie speaks out about what will happen if Ealing A&E is shut: ‘The consequence of closing Ealing A&E will be more dead babies and very sick children,’ said paediatrician Colin Michie. ‘The idea of shutting the A&E without providing extra capacity elsewhere is quite frightening. There is a complete disparity between the plans and reality.’
 Taken from The Sheffield study pre-dates the closure decision, however, I have raised it with NHS managers and never had a satisfactory reply for why it does not mean Redbridge residents will be put at risk if KGH A&E is shut.

Thursday, September 20, 2012

Mr Hunt to save A&Es?

The Independent is running a story that Mr Hunt is about to do a U turn on A&E closures. It is not confirmed.

Monday, September 17, 2012

The Secretary of State should think again about plans to close A&E and Maternity services at King George

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.

Thursday, September 13, 2012

“Hit Squad” for BHRUT or for East London?

Neil Zammett writes
The announcement by Simon Burns the former Health Minister that a “Hit Squad” is to move in on BHRUT seems to be good news. Not surprisingly the minister blames the previous government for the parlous financial state of the beleaguered Trust and he has a point because the very large investment represented by Queen’s hospital had both Department of Health and Treasury approval.
On the other hand the previous government was arguably more responsible for the performance of the overall policy of PFI rather than a few problematic cases. The Minister will be viewing events from a different perspective now-I wish him well.
Those responsible locally faced a very real dilemma in approving the Queen’s development. Of the two hospitals it replaced, Harold Wood was a largely hutted complex of buildings left over from the emergency hospital built during World War Two. There had been some new build for example the maternity unit but most were totally unsuitable for 21st century medicine.
Oldchurch represented one of the worst examples I have seen of piecemeal development in a constrained town centre site. Buildings from various era in a poor state of repair were huddled together often with no logical functional relationship.

The original solution was to build on at Harold Wood because it was the larger site and the huts were easier to demolish. It soon became clear that NHS funding would only be available in dribs and drabs and that population and access pointed towards a development in Romford. The “Ice Rink” site represented a once in a generation opportunity to combine the two hospitals using the PFI and despite an initial “wobble” when the developers looked about to pull out the local health authority decided to recommend the development.
At the other end of the “patch” in Whitechapel the new billion pound Royal London PFI is also the outcome of a tortuous decision making process. I was peripherally involved when Colin Berry was Dean and again site problems, shortage of higher education and NHS funding and ageing buildings were strong drivers behind the PFI solution. The situation has been exacerbated by smaller scale investment at Newham and Whipps which have been merged into Barts Health because they were not financially viable.
This sort of logic is the root cause of many our current financial difficulties. As in South London we have a number of very expensive solutions to building problems which were not part of a coherent strategy which looked at long term affordability. Individually they may have made some sense, but there is now an emerging issue of whether the population in East London can generate enough “business” to pay off the debt these developments have incurred.
I share the view of many others that as central government approved the PFI schemes the final responsibility for under writing the excess costs lies with them. In the case of BHRUT we know from the Auditors’ Public Interest Report that the PFI costs about 50% more than the average, an additional cost of around £15 million per annum by my calculations. They should start paying this up front now to take some of the pressure off the Trust. You don’t need a hit squad to work that out.
The new PFI at the Royal London is part of the merged Bart’s Health now and the financial advisors estimate that the savings in back office staff will come to £30 million per annum- equivalent to about 1000 jobs. The merged Trust has an underlying deficit of £26 million for Barts and the London and £15 million for Newham and Whipps. For 2012-13 this is supported by the use of mainly non-recurrent reserves but after this the financial performance of the Trust will be largely dependent on its ability to make savings.

To me this scenario looks ominously similar to the troubled South London Trust where three financially “challenged” organisations with big PFI debts were merged only to effectively become bankrupt because the estimated savings could not be achieved. I sincerely hope I am wrong but a billion pounds sounds like a lot of money to me, you can’t even dial that on your telephone.
To add to the problems of strategy; the Royal London PFI was excluded from the Health4NEL exercise so we have no idea of its impact on either financial viability or service configuration for East London as a whole. What we urgently need now is a proper strategy for East London which looks ahead to 2022 and integrates the plans for BHRUT and Barts Health. This is what the “Hit Squad” should be concentrating on.

Tuesday, September 11, 2012

"Hit Squad" to come to BHRUT

The Telegraph has reported at that "hit squads" are to visit BHRUT and other NHS trusts.

It would be helpful if BHRUT were to say exactly what these squads of accountants and lawyers will do as of today there seems to be nothing on the news section of their site about this.

Tuesday, September 4, 2012

BHRUT admits that there is likely to be a demand for 90 acute beds which had not been included in the Health4NEL Business Case

Neil Zammett writes
I am picking up in this blog the issues around A&E and maternity at King George because further information has been forthcoming in the September BHRUT Board papers. Nick Hulme who is the officer in charge of re-configuration told their July meeting that:
“Several meetings had taken place to discuss demand and activity assumptions which had changed significantly since the original plan. Mr. Hulme informed the Board that demand management assumptions had also been discussed and agreement reached with the Cluster that there was likely to be a demand for 90 acute beds across both sites, which had not been included in the original Health4NEL business case.”
This confirms that that BHRUT are now putting together a new plan which revises the bed numbers in the original. The figure of 90 is presumably the outcome of this work. It does not explain how these additional beds relate to the closure of A&E but it does confirm my view and that of many others that the original proposals were base on hopelessly optimistic assumptions. The original plan estimated that some 250 beds would have to close across the two sites to allow A&E at King George to shut. Presumably the latest study has estimated that only around 160 can be closed on their (unknown) timescale.
It is instructive to contrast the above quote with that from page 91 the original business case:
“The trust and local stakeholders recognise the challenge that this change represents. The reduction of 250 beds by 2013-14 represents 22% of the bed base. However a comparison of other trust’s length of stay against national benchmarks indicates that a considerable reduction in length of stay should be achievable. Without this reduction the closure of the King George A&E cannot take place.”
To date there has been no sign that the length of stay of emergency admissions at Queen’s can be reduced to a level which would allow the closure of A&E at King George. In fact the reverse is true, increased demand has led to appalling delays in transferring patients from ambulances and bed numbers have not reduced at all.
The new plan has not however been included in the September Board papers and there is no reference to it that I can find. Obviously the plan is a very significant document that is a matter of legitimate public interest.
Although Nick told us at the last JHOSC meeting that the new plan has a very provisional closure date of late 2014, a year later than originally planned, this date is dependent on central government approval for the scheme which was originally estimated to cost around £10 million there is no mention of this in the BHRUT Board minutes.
Neither is there any reference to his statement that approval will be dependent on the affordability of the scheme and the ability of BHRUT to come up with a plan for long term financial viability. As BHRUT is losing around £1.0 million a week at present I think the odds are pretty much stacked against this happening.
The situation for Maternity is rather different. The Cluster PCT has imposed a limit of 8000 births at Queen’s and women from the West of Redbridge are now being directed to Whipps and Newham. This “cap” was not part of the original agreed plan and will restrict choice for women. It will also help to force the closure of maternity at King George.
This will be done against a background of rising births in East London where we have amongst the highest rates in the UK and in Redbridge in particular where we have the second highest number of under-five’s in London.
The rationale for closing Maternity was largely based on the need for co-location with A&E and if it remains open then the whole plan needs revising. On its own closing Maternity at King George will not save any money and medical staffing requirements for a unit of under 2000 deliveries per annum are much less onerous than those for larger units.
Smaller units may also offer a more attractive recruitment environment and this remains an unknown quantity in East London where we are going to have massive units delivering over 9000 babies per annum, much larger than the current biggest unit at St Thomas’ with 6500 deliveries a year. No one knows if we will be able to recruit to these units
What we do know is that local women are very much against the closure of King George. Research conducted by Health4NEL has shown that while women have a good conceptual understanding of choices in childbirth the way that systems operate deny women that choice in practice.
The restrictions imposed by the PCT are going to make this even worse for local women with up to 40% not having the choice of a consultant led delivery, as opposed to about 2% now, and only a very few women having a choice of unit. Women right across East London will have to travel further to have their babies.
I would like to see the Council take the following simple steps:
1. Asking to to see and evaluating the revised plan for A&E at Queen’s. They need to check that this plan looks at least ten years ahead to allow for population growth locally and how the extra 90 beds are going to be configured and that it is consistent with a broader strategy for East London which looks at investment policy and the impact of the new Royal London development.
2. Seeking an acceptance by health that the closure of A&E at King George now needs to be reconsidered in the light of the new demand forecasts.
3. Using Health Scrutiny’s existing powers to ask for formal consultation on the changes to maternity services and to make sure that systems are in place to enable the majority of women to have the choices about style of birth and location which are national policy.
4. Asking for a proper workforce strategy for maternity services in East London which shows how increases in demand are going to be met.
5. Pressing at least for the continuation of the existing consultant led unit at King George to act as a buffer for increased demand.