I attended the Joint Health Overview and Scrutiny
Committee (JHOSC), the scrutiny committee which covers Havering, Barking and
Dagenham, Redbridge and Waltham Forest on Monday 8th October and took the opportunity to ask Averil
Dongworth the Chief Executive of BHRUT what the current position on the closure
of A&E at King George was.
Her reply indicated that there has been no further
progress since Nick Hulme told the previous meeting that there was a very
provisional date of 3rd quarter 2014, dependent on the outline business case
(OBC), for an extension of the A&E department at Queens being
approved.
She did
say that she is not happy with the current situation; they are getting closer,
however.
In view of this I thought it would be useful to re-visit
the forecasts in the original Decision Making Business Case (DMBC, see page
92).
These
showed that around 250 beds would have to close by 2013-14 to allow for the
closure of A&E at King George, while to date the Trust is showing
60-70.
This is not a “near miss” but a very significant under
shoot which warrants further explanation; how could the original forecast been
so far adrift?
There are three factors which affect future occupied bed
numbers at any hospital. The first is length of stay reductions primarily for
emergency admissions, the second is the assumptions which are made about demand
management again around emergency admissions and the third is growth driven by
population change and referral patterns.
It is a particularly complex problem because length of
stay reduction has to be balanced against growth in demand. It is a bit like filling a tank with
a hole in the bottom with water. As the water runs out {length of stay reducing} water
runs in {demand increasing} the water level {the number of occupied beds} rises
or falls with the differences in rates of flow.
Length of Stay
In the original DMBC plan this was anticipated to be the
biggest source of bed reductions with 331 going at BHRUT by 2016-17 and 250 by
2013-14.
Nationally length of stay has been reducing for a long
time and recent trends[1] from 2000-01 to 2009-10 show that in
the decade it has reduced by 32% or just over 3% a year. This is not the full picture because
in later years, from 2007-08, the decline has slowed and “flattened”
out.
One of the problems with the forecasts in the DMBC was
that local managers were allowed to input their own value for length of stay; so
managers at the Homerton forecast a reduction of 6% in the five years to 2016-17
which is very unlikely, while those at BHRUT forecast a 29% reduction, equally
unlikely given the national figures would suggest a value of 15-16%.
In my briefing note for January 2011 I drew attention to
the need for some form of validation of the very large length of stay reductions
proposed for BHRUT because this was such a critical part of the overall
plan.
Demand management
Demand management is shifting elements of work and
therefore hospital admissions to primary care and community settings,
principally the GPs. This results in lower demand for
beds.
It was a much smaller component of bed reduction
forecast in the DMBC and accounts for just 37 beds in BHRUT as a whole by
2016-17. Over the East London as a whole the figure is just over
100 beds.
This is
however dependent on GPs having the capacity to take on additional work
particularly for long term conditions such as diabetes.
We know however that primary care in Redbridge has a
high number of singlehanded practices, many buildings needing replacement or
major refurbishment and a “bulge” of doctors nearing retirement
age.
These
factors make it very unlikely that demand management will yield the reductions
forecast.
I would therefore be inclined to exclude demand
management from forecasts, particularly as it is such a small figure and there
is no evidence that it has occurred in East London over the past two
years.
Activity Growth
Unlike length of stay, growth was determined by the team
which put together the DMBC and used a combination of population forecasts,
largely from the GLA and estimates of non demographic
factors.
Without
further information it is difficult to make detailed comments but overall the
values used appear reasonable except in the case of Tower Hamlets where for some
reason a negative growth factor appears to have been
applied.
There does, however, appear to be an arithmetic error in
the table on page 91 where an allowance for the growth at the supposedly closed
King George hospital has not been included in the Queen’s
figure.
This would
add an extra 60-70 beds to the 107 shown.
Nationally admissions have continued to rise
consistently by about the same amount as length of stay has reduced about 3%,
roughly compensating for the impact of length of stay on bed numbers.
Where does this leave us?
What this amounts to at BHRUT is that the value of
length of stay used for a five year forecast was more likely to occur, on
average, in around ten years. A separate forecast for two years up to 2013-14, the
notional timing of the closure of A&E, showed a 22% reduction which, on
average again, would be more likely to be achieved in seven years using the
national average of 3% per annum.
Additionally, individual hospitals are sensitive to
local circumstances such as the availability of nursing home and community
hospital beds with clinical practice and staffing levels being factors as
well.
Predicting
large reductions like this for one hospital over a two or three year period is a
very risky exercise with a high margin of error- a point which again I wrote
about in my briefing note of January 2011.
Although there was some sensitivity analysis in the
DMBC, which quite rightly picked up length of stay as a key variable, this was
presented separately from the main analysis of future bed numbers which made the
results look much more precise that they actually were.
Decision makers at the December 15th 2010 JCPCT will have believed that they were looking at
forecasts which were absolutely precise and showed that bed numbers at BHRUT in
2013-14 almost exactly matched the number necessary to close the A&E
department at King George.
For an individual hospital the factors listed above add
up to a very volatile forecasting environment. Any results from future exercises
therefore need to be treated with considerable caution as has been demonstrated
with the current uncertainty about the closure of A&E at King
George.
We will not have the full picture of the Trust’s, and
the North East London and the City PCT’s, latest thinking and methodology until
the OBC is available and we get an opportunity to review the latest assumptions
and projections.
This is now a very important document because it will
replace the DMBC as the basis for decision making, at least as far as A&E at
King George is concerned.
How can we move forward?
There is no doubt that the current situation is a very
uncomfortable one. Now that the forecasts for bed reductions at BHRUT in the
DMBC have been shown to be far too optimistic we need to have a new plan to move
forward.
Given the
experience of the DMBC, this plan to have a much higher degree of flexibility to
allow for the volatility of the forecasting environment.
Equally uncomfortable are the implications of the
failure to close A&E at King George on anything like the proposed timescale
on the overall financial and service position of East London. I would add that this does not
diminish the promising work done at Queen’s to improve performance in A&E on
the four hour wait target and black breaches.
All of this points towards a review of the whole plan
drawing on the experience of the past two years. It should also address some of the
shortcomings of the DMBC by extending the timescale to ten years which would
allow for population growth to be more adequately reflected. It needs to include the Royal London/
Barts PFI which will have a huge financial and service impact on East London and
the issue of surplus acute beds in Inner London.
The important issue of investment, debt and the long
term financial viability of trusts is an integral part of any sound strategy. As
it stands the plan, or what is left of it, looks very biased towards Inner
London with Redbridge and Barking and Dagenham being the major
losers.
There is also the linkage with maternity which is
closing on the proposed timescale, albeit with a radically different plan
including the Homerton and shelving the plan for a midwife led unit at King
George.
An uncomfortable situation again given that the
co-terminosity of A &E and Maternity was one of the main planks of the
DMBC.
Additionally there is the issue of workforce planning
for obstetricians and midwives. The DMBC contained some rudimentary spreadsheets but
these were obviously inconsistent with some of the service changes. We still
have no idea if we can recruit the number of midwives we need for the rising
birth rate or if the proposed “super units” delivering over 9000 babies a year
represent a viable recruitment platform.
What we need is:
1. To see and evaluate the revised plan for A&E at
Queen’s, the OBC. We need to check that this plan looks at least ten years
ahead to allow for population growth locally 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/Barts development.
2. To seek an acceptance by health that the closure of
A&E at King George now needs to be reconsidered in the light of the new
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.
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