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.

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