Tuesday, January 21, 2014

Re-visiting the Health4NEL Plan

 Neil Zammett writes
This month’s blog re-visits the review of the DMBC I wrote exactly three years ago.   Sadly it is all coming true and my forecasts of problems over length of stay reductions, the balance between Inner and Outer London and the impact of the Royal London rebuild are being fulfilled.
The emerging truth is that the Health4NEL plan was deeply flawed and so heavily biased towards Inner London in general and Tower Hamlets in particular that an unstable situation has been created which can only be sustained by some form of substantial external intervention of which finance is an important part.
It is not BHRUT that need to be put into “special measures” it is the National Trust Development Agency for continuing to follow an outdated and badly through plan.  Without more resources local hospitals will continue to fail, effectively subsidising surplus capacity in Inner London.  This is not just unfair it does not make long term service or financial sense either.
The review below is more of an essay than a blog but I would encourage readers to stick with it and read it right through.  It is very rare in my experience for prophecies to come so comprehensively true.
Review of the Health4NEL Decision Making Business Case
I have reviewed the Decision Making Business Case (DMBC); the 200+ page document which was presented to the JCPCT as the basis for their decision to close A&E and Maternity services at King George at their meeting on December 15th 2010. As always these are my personal views aimed at helping elected members contribute to the decision making process.
For those members who do not wish to read the whole document I have included a brief conclusion below:
The three main issues from the DMBC are; geographical equity between Inner and Outer London, the impact of surplus beds in Inner London and the feasibility of reducing bed numbers at Queen’s/King George in the time scale proposed.
Further work is required to give a definitive view but prima facie there are imbalances, the issue of surplus beds after the BLT redevelopment has potentially very serious implications which have not been addressed and no external view has been taken on the proposed 250 bed reduction by 2013-14 at Queen’s.
The case for the closure is based in large part on the results of a mathematical activity and capacity model.  This uses very large data sets based on health resource groups to predict the financial and patient flow effects of closures.
 Health resource groups are small sets of hospital operations and procedure which have costs and operational information such as length of stay associated with them.  There are several hundred of them and they are used primarily to calculate income for the payment by results contracting system.
The overview of the model and main results are shown in pages 75-96 of the DMBC and a fuller version is given in pages 18-30 of the appendices.  There are also additional sections on the costing which I have not explored in any depth. I do not propose to go into detail but feel it would be most helpful to make some high level comments on the model.
I would see its strengths as the ability to link income and activity together accurately and therefore to predict the effects of closures.  It also separates out the effects of demand forecasts, efficiency improvements, demand management and reconfiguration on caseload and bed numbers.  Finally it covers A&Es and outpatient attendances, and births, planned and emergency admissions which make it comprehensive.  Results are presented as a series of tables and diagrams which show changes in caseload and attendances for different time horizons (2013-14 and 2016-17) and also forecasts of bed capacity by hospital.
In terms of weaknesses: the model does not treat day cases, those patients who remain in hospital for less than a day, separately. This is a significant omission because day case rates vary considerably and have a major impact on bed usage. Unlike some earlier models it does not try to optimise some objective function such as admission rates for each borough and therefore has no baseline measure for equity. 
There is an additional point that is nothing to with the model itself and that is the major PFI development at Barts and the Royal London which will be coming on stream in 2012  has not been included in the future scenarios.
This being said the model is in my view a very useful tool and the results have been reported and illustrated particularly well, but need to be carefully interpreted because of the weaknesses.
The Results
Looking at the results generally I was struck by the differences in capacity for inpatient spells at the six hospitals.  Barts and the London (BLT) are clearly the largest at around 84,000 with Whipp’s and Queen’s not far behind at around 70,000.  Newham and King George are quite a bit smaller at 44,000 with Homerton by far and away the smallest of the group with only around 38,000 spells. King George is therefore in quite a big way of business and by no means the smallest of the six.
Looking at efficiency; there are no LOS tables provided in the DMBC so I did a quick check by adding the non-elective and elective spells for 2010-2011 for each hospital and the dividing by the number of beds.  This gives a throughput per bed, not the same as LOS but easier to calculate and a good simple measure of efficiency.  On this basis King George had a figure of 112 spells per bed against Queen’s 94.  In simple terms this would mean that transferring the King George workload to Queen’s would require 20% more beds because their overall efficiency is lower.
Although these calculations are very crude they show the importance of looking critically at existing performance as part of the context.
Obviously summarising the results of such a large piece of work is difficult and I have concentrated on the forecast bed capacity tables; 3.6.1-3.6.6 on pages 90-96 of the DMBC because these are really central to the issues around closure.  One of the things that became clear to me straight away is that the efficiency gains from LOS reductions varied enormously between hospitals even allowing for their size,
It appears that different assumptions for each hospital have been used which makes the interpretation of some of the results quite complicated. The reason for this appears to be that the ‘managers’ of each hospital have been allowed to select their own assumption about gains in efficiency.  Incidentally the forecasts for expenditure have also been left to individual hospitals.
 The Homerton, the smallest hospital has opted for no reduction while at Queen’s /King George managers have selected a 22% reduction by 2013-14. Although the report does say that comparison with bench mark figures indicates; ‘... that a considerable reduction in length of stay should be achievable.’ it stops short of endorsing this particular level or being more specific about the nature of the comparison which was undertaken.
I feel that this lack of consistency undermines the conclusions of the modelling exercise in the sense that the results are based on different LOS inputs. The model is not therefore predicting an outcome in terms of beds although it might look as if it is; this is determined by the inputs. Equally allowing the Trusts to input their own expenditure forecast without a consistency check raises questions about the validity of the financial part of the model as well.
I would stress that these are not criticisms of the model per se or the way in which the results have been presented but more the way in which inputs have been allowed without consistency and equity.
The Impact of the Barts and the London PFI
On page 95 of the DMBC the author writes; ‘At Barts and the London the forecast saving from reduced length of stay exceeds the amount needed for new demand giving a net surplus of beds of 103 by 2014-14 (increasing to 113 by 2016-17). However this is based on the current bad base; in 2011 the new buildings at the Royal London and Barts open and this increases capacity thereby increasing the potential surplus.’
The Skanska website shows the bed numbers in the new build as 1248 an increase of 267 on the 2010-11 bed base in the DMBC. Reference to page 11 of the executive summary of the Business Case for the new BLT shows a final figure of 1248 as well but indicates that 250 beds will be ‘mothballed’.
Taking the 1248 figure with the DMBC estimates would give a surplus of 370 by 2013-14.  My contact at Health4NEl does not have a comparable bed figure for the new development which could include day case beds, so this figure needs to be treated with caution.
When one compares this with the estimates of 400 or so actual beds for Newham and 319 for Homerton it is evident that even allowing for some forecasting error there are going to be some very difficult issues to face in Inner North East London.
This admittedly superficial analysis raises a number of very serious questions about the way in which plans for North East London (NEL) have been developed over the past ten years or so.  On the one hand in the three outer boroughs bed and hospital numbers are going to be dramatically reduced while in the inner three there is an existing bed surplus which will be increased by the mothballed beds at BLT.   These are not small bed numbers. The surplus at BLT would equate to an average local hospital and the reduction at King George manifestly is.
The key issues here are;
Equity between geographical areas
The impact of the very large surplus bed at BLT
The feasibility of reducing bed numbers at Queen’s/King George in the time proposed
Equity of provision
There is a very real question about of provision between Inner and Outer London. In very rough terms the surplus of beds in Inner London by 2013-14 equates to the bed reductions in Outer London.  If we take the three outermost Boroughs there will be one hospital for 700,000 people and if we take the three innermost, three for around 650,000.
Equally there will be around 740 beds for the outer three and 1970 for the inner, nearly three times as many.  This assumes that all of the extra beds at BLT would be opened.  The status of the ‘250 ‘mothballed beds needs urgent clarification therefore.
The position of Whipp’s Cross ‘vis a vis’ the local Borough is an interesting one.  The hospital is large for the local population and always has been and it represents a pivotal location for health services because it is well placed to serve parts of Redbridge.  In the DMBC analysis it is a gainer or at worst not a loser.
Placing Whipp’s in the Outer London Zone tends to give a false picture of relative provision with Inner London because it is so large and therefore masks the impact of the closure of King George on the three Outermost Boroughs.  In order to get a really fair picture more information is required on inter borough patient flows to give catchment populations for each of the hospitals.  This is a really important piece of work.
However the bed surplus at BLT clearly creates an imbalance starting off with a minimum surplus figure of just over100 beds in 2010-11 and a bed complement of 981. There will also be a much smaller future surplus at the Homerton.  This has not been estimated because they were allowed to opt-out of the LOS reduction exercise
All of this should in my view have been explored in more depth in the DMBC.  I cannot understand how the issue of equity could have escaped people’s attention when it seems so obvious to me.  Equally I cannot understand why the issue of the surplus beds at BLT has not been addressed. 
In fairness the author does specifically mention the point and gives the figures but the potential impact on the proposals have simply not been dealt with.  As I have stated more information on patient flows is necessary to make a proper judgement.
Impact of the beds surplus in Inner London
With such large potential numbers of surplus beds in Inner London I would have expected the DMBC to be addressing the issue in some considerable detail.  Members of the JCPCT did not pick up on this point but given the quantity of material they had to deal with this is not altogether surprising.
 In the current climate large bed surplus’ lead to financial and service instability. I am not sure what the thinking behind mothballing the 250 beds at BLT actually was, but even without them the logic behind closing beds in Outer London while maintaining an existing large surplus in Inner London is hard to fathom.   This must put enormous financial strain on the system quite apart from the issues of equity.
There is an inescapable conclusion that had these facts been included in the original decision making process the outcome could have been very different.  If the current proposal goes ahead there is also clearly an enormous risk in financial terms to the stability of the health economy in North East London. 
Feasibility of bed closures
Because trusts were allowed to choose their levels of LOS reduction there was no independent check on feasibility  So at the Homerton no gains were forecast which is a very unlikely outcome while at Queen’s/King George a reduction of 22 % was forecast to 2013-14.  The author acknowledges that ‘The Trust and local stakeholders recognise the challenge that this represents.’
What is needed here is some check against LOS reductions in parallel situations to see just how possible this scale of reduction is. There is obviously the danger of making this a self fulfilling prophecy by simply closing the beds in question with potentially serious effect on services and the public although this is unlikely. Time scales are all important here as well.  Trying to do what is possible in ten years in five could have serious consequences.
Again in fairness the author of the DMBC sounds a warning note ‘Without this reduction the closure of the King George A&E department cannot take place.’
I have placed my conclusions in the summary section at the beginning of the document. I would simply add here the thought that one of the problems with reviewing this type of document is the quantity of material involved which goes well beyond the document itself and includes other large documents like the BLT Business Case.
Finally a caveat that although this represents my best efforts but, this is a highly technical area crossing several disciplines and quite a bit of further work is necessary by specialists to really bottom out the issues.

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