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that need to be put into “special measures” it is the National Trust Development Agency for continuing to follow an outdated and badly through plan.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

Background

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 15^th 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.

 

Introduction

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.

Discussion

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.’

Conclusions

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.

How will Queens cope if KGH A&E Closes?

Bary Fleetwood writes

The A&E Question of Queens and King George

LARGEST A&E  TRUSTS

                                                    Patients attending per year

Barts Trust                                       4 A&E Units       290,000

Heart of England Trust                    2 A&E Units       240,000    

Pennine Acute Trust                        4 A&E Units       240,000

Mid Yorkshire Trust                       3 A&E Units        210,000

Lewisham & Greenwich Trust       2 A&E Units        210,000

Leeds Teaching Trust                     2 A&E Units        200,000

BHRUT                                         2/1 A&E Units    199,000

After Reconfiguration, BHRUT will be the largest one unit A&E in the country, there must be serious doubt that they can design and operate an A&E this size with any success

WORST TRUSTS WITH GREATER THAN 4HOUR WAIT

(for w/e 15/12/2013)

Hospital               Seen in less than 4hours

1.Mid Staffs                             76.0%

2.Portsmouth Hosp.                   78.1%

3.Kettering General Hospital        80.2%

4.Southampton Univ.Hosp           80.9%

5.King's College Hosp                  82.4%

6.East Lancashire Hospitals          83.0%

7.Milton Keynes Hospital              83.8%

8.BHRUT                                          85.1%

9.Somerset and South Glos.             85.2%

10.Nottingham University Hosp       85.4%

The absolute refusal of ministers and the Trust to even reconsider the Closure of King George A&E is simply a disenfranchisement of the Voters of BHR Trust Hinterland, but not only these three boroughs but abutting boroughs  you have an arc from Epping through to Grays that may use Queens, this makes close to a million people served by Queens.

We do not yet know how big the reconfiguration for Queens will be but, it will certainly not be enough, and the irony is that as the population of this part of London explodes, and the rest of the population ages, it is likely that by 2020 (with perfect sight) the Trust will almost certainly have to open another A&E because Queens will be in the same position as it is now, trying to push a gallon into a pint pot.Currently Queens A&E is trying to cope with 130,000 patients p.a. when its capacity is only 90,000 is it any surprise it cannot cope.The 2010 Consultation imposed on BHRUT was flawed then and now bears no resemblance to reality 4 years and  population increases later, but blinkered Ministers NHS England and NDTA cannot be seen to admit they are wrong.We also know that Queens will be the largest single A&E unit in the country, and we also know that the very largest A&Es are not as effective as  medium sized A&Es.The Raison d’etre for closing KG in the consultation was to consolidate services and make them better, saving money we were told was not a consideration, except we now know that this was simply an outright lie, or outright stupidity by the authors. 

Let us examine the Reconfiguration, most of which is now public knowledge for King George, which will go from a modern Acute General District Hospital to the largest Polyclinic in the world, with no A&E, not what it was built for.The Trust has not been in the least bit honest,it has laid out what bits of the hospital will be for what purpose, and said “Those parts not used we will find uses for” which we all know is Trustspeak for selling off as much as possible.

Although the Trust does not publish the A&E split between KG and Queens (however this will shortly be remedied.)from the little information that is available, it would appear that KG is close to the 95% 4 hour waiting time target ,whilst with an average last week of 84.1% the worse than we think performance of Queens is hidden, it is probably somewhere near 76-79%.Nor will they publish the split of patients between KG and Queens the only figures are from a very obscure  document “Quality Account” 2012-13 (this omission will also shortly be remedied)

These figures are a year old so they have probably increased, this does not agree with the other figure for Queens which is bandied about and in several documents of 130,000 a year, there are anomalies in the figures above as the daily figures do not correspond with the yearly figures, The statistics reported to NHS England every week appear to support about 200,000 patients a year in A&E for both KG and Queens, so what is true, this produces a number of  questions

What figures can we believe?

Does the Trust actually know what the figures are?

.

Although the KG reconfiguration has been published, absolutely nothing has been published for Queens

These questions remain unanswered

The current alleged capacity of Queens is 90,000 p.a. NO Capacity has been promulgated for the Reconfiguration.

The cost of the Reconfiguration, appears to be unknown to both the Public and The Trust itself,The Trust this Financial Year will have a deficit of between £27 -£33 million, to add to the already existing £100M + deficit, just how does the Trust propose financing the Reconfiguration?, The reconfiguration is not going to be cheap, is likely to be many millions rather than a few ,

Ministers , Trust Executives and CCG executives have all used the phrase “KG A&E will not be closed until it is “Clinically safe to do so”, The Minister has refused to name the criteria to be used, the Havering MPAndrew Rosindell has ignored a request to ask the minister to name the criteria and quantitive figures to measure “Clinically Safe”, NO-ONE seems to know what this phrase means, one has to believe that CLAIRVOYANCY  is the going to be the method of determining “Clinically Safe”.

Now let us examine how big the reconfigured A&E should be, currently we have for Queens any where from 130,000 to to 147,000 and for KG anywhere between 73,000 and 100,000, (of course what this does point up is that the Trust is simply not consistent with its figures-the Trust believes – with no supporting evidence (and I believe it is simply a guestimate) that 30% of KG A&E patients will transfer to Queens A&E when KG is closed. In my opinion this is a fallacious argument probably a much higher percentage  will transfer , when people want an A&E they want an A&E not a pale imitation as is planned for KG So at the very minimum according to the Trust (and we have already demonstrated their figures are hugely suspect)there will be between 155,000  and 177,000 with  a possible  high figure of between 230,000  and 257,000, to add to this the NHS recognises and has published  that for a new A&E for the first 6 months there is a 15-20% increase over and above the normal number of patients.This takes no account of any increase in population which will increase the call for A&E facilities especially for children. The other point is that no mention has been made of  future use, even though the Trust is legally bound to publish a 5/10/20 year plan and forecast for a new A&E

We already know that very large A&Es’ perform significantly worse than the smaller ones, which is frightening for Queens for it to reduce its performance from an already dangerously low point.The people of the three boroughs expect and deserve something infinitely better. The original Consultation said that the reconfiguration would deliver a much safer, better performing and more efficient A&E  if as is likely that the Unit might have to deal with nearly a quarter of million patients a year does anyone actually believe that? And we have not even considered the huge number of Consultants, middle range and junior doctors that will be needed, along with nurses and support staff, none of which vacant positions the Trust seems able to fill. We have yet to see the alleged 30+doctors from India actually in place and REMAIN in place once here. One also has to wonder about both their suitability ,experience and temperament to operate in the high pressure of A&E.

Having said all this about Queens, the A&E itself is in an impossible position, trying to put 130,000 a year into a 90,000 a year pot. Every part of the system is responsible for the failure of Queens, CCGs Councils and not helped by the failure of Scrutiny Committees and the CQC which gives local  GP practises with 18 day waits for an appointment a clean bill of health, they have no incentive to improve, not least the Councils themselves, where home care either is not in place or fails, which means that the elderly infirm and disabled get taken to A&E instead of being dealt with by carers and GPs.

The pressure on A&E can only be resolved by ensuring that the other parts of the system work effectively, GPs with reasonable waiting times, CCGs ensuring this is so, councils spend enough on home care, and Scrutiny Committees making sure they all do their job correctly, otherwise what you end up with is that A&E does the GPs job for them, and under those circumstances every single A&E in the country will fail. We know that GPs and CCGs are failing to relieve the pressure on A&Es there is no reason to believe that the third part the Councils with home care, with budgets under huge pressure are any different and failing despite Council spin to the contrary.

Scrutiny Committees have so far have shown very little evidence that they also have a grip on the situation or have any effective influence on any of the participating partners.

It is a truism that all Outer London Hospitals have suffered from decades of under investment and under funding, the money has all gone to the “Glamorous” Teaching hospitals in Inner London, making them some of the best in the world, but depriving the rest of London of desperately needed funding-just look at how much equipment has been provided by groups of “Friends of the Hospital”. The problem is not nearly as bad in the rest of the country, where funds are spread much more evenly, rather than concentrated on Teaching Hospitals, drawing money away from the very hospitals that treat the 1000s everyday   in Outer London. The Government and NHS England urgently need to review the funding for all Outer London Hospitals.   

The cost of Reconfiguration has not been published as yet however this is not going to be a cheap operation it will not be £2/3 million, We do know that the Chase Farm/Barnet Reconfiguration cost – hold onto your seat- £114 million, so how much money was saved there? So our reconfiguration is quite  probably going to be in the tens of millions, and one has to ask the question is it actually going to save any money in the foreseeable future, would this money not be better spent retaining both A&Es? The Trust is frankly bust, with an accumulated deficit of over £100 million and forecast deficit of between £27 -£33 this year, so the money has to come from somewhere else, hopefully not from the PFI Partner, as the PFI agreement is partly responsible for the Trusts cash problems, this really only leaves the NTDA (The NHS Trust Development Authority)

In this climate is the NTDA actually going to be able to rustle up this level of money? Bearing in mind there may even be a change of Government in between. In all honesty, what makes more sense is to invest this money in both A&Es, as has already been said by 2020 it is quite possible that we will need another A&E anyway.

We have to praise the Staff of KG and Queens A&E for doing an almost impossible job, with great skill and fortitude, under an almost impossible pressure, this is due to enormous under funding, a failure of other parts of the system and the stupidity of trying to enforce a flawed and unwanted 4 year old consultation, with Senior management stuck between a rock and a hard place.  

Mike Gapes batting for King George in Parliament yesterday

Thank you to Barry Fleetwood for sending me the below

 Mike Gapes Adjournment Debate on BHRUT 0n 9th January-with Ministers Reply

 Mike Gapes (Ilford South) (Lab/Co-op): Madam Deputy Speaker, I would like to ask you to convey my thanks to Mr Speaker for selecting this Adjournment debate today. On the last sitting day before Christmas, I asked for this debate because of what I considered to be the bad behaviour of the Secretary of State for Health. I was informed on 17 December that an announcement would be made the following day—embargoed until 2 pm—that would have profound implications for my constituents and the many other people in the London boroughs of Barking, Havering and Redbridge. That announcement, by the chief inspector of hospitals, Professor Sir Mike Richards, was that the Barking, Havering and Redbridge University Hospitals NHS Trust was to be put into special measures following inspections by the Care Quality Commission. I attempted to raise the matter by intervening on the Secretary of State during a debate that took place following the announcement. I waited until after 2 o’clock so as not to break the embargo. I stood several times, but he did not accept my intervention. I therefore thought that the least I could do was to put in for an Adjournment debate on the subject, and I am grateful that it has now been chosen. I have also raised a point of order about this matter. That was not the first time that I have found Ministers reluctant to engage with me directly on the question of the NHS trust that covers the King George hospital in my constituency as well as the Queen’s hospital in Romford. Nearly a year ago, on Thursday 7 February, I took part in a debate on accident and emergency provision in London. I asked the then Minister, the hon. Member for Broxtowe (Anna Soubry)—who has since been moved away from Health—to respond to my request to set aside the decision of the previous Secretary of State, the right hon. Member for South Cambridgeshire (Mr Lansley), in 2011. I also asked for the decision to plan for the closure of the accident and emergency department at King George hospital within two years of October 2011 to be reconsidered. The then Minister failed to respond or even to mention the King George or the Queen’s hospitals in her response to the debate. I have tried on several occasions to get ministerial responses to my requests to reconsider that decision. It was clearly a strange decision, given that we are now in 2014 and that—for reasons I shall outline—the timetable and the absolute chaos of this failing NHS trust make it absolutely impossible to close the accident and emergency department at the hospital in my constituency. Sadly, in 2013, we lost our maternity services, which have been transferred to Queen’s hospital. I asked the Secretary of State to reconsider this issue, but on 15 January 2013 he said: “The decision has been taken”. However, he also said that “we have made it absolutely clear that we will not proceed with implementing it until there is sufficient capacity in the area, particularly at Queen’s hospital in Romford, to cope with any additional pressures caused by it, and that undertaking remains.”—[Official Report, 15 January 2013; Vol. 556, c. 734.] 9 Jan 2014 : Column 555 I asked him again in May, and I got a similar answer. I was told that it “will not be closed until it is clinically safe to do so.”—[Official Report, 21 May 2013; Vol. 563, c. 1064.] What is the current situation? The Care Quality Commission published its report in December. That report does not just deal with accident and emergency; it also raises issues relating to other departments in both Queen’s hospital and King George hospital. On Queen’s hospital’s accident and emergency department, it states: “The service is not responsive enough to people’s needs. People were waiting too long to be either discharged or admitted. The trust is not dealing with enough people within the national four-hour target. The initial care pathway for children does not meet their needs, and unnecessarily delays their initial assessment. Queen’s Hospital has consistently failed to achieve the 95% NHS target for the number of attendees that were discharged, admitted or transferred within four hours of arrival. Between the 1 April 2013 and 8 September 2013, 9,359…out of 59,038 patients were not seen within four hours of arrival. The department struggles to meet the target at all times, however, Mondays and Sundays provide the greatest difficulties. The A&E at Queen’s…performs significantly worse than at King George Hospital. These delays mean that patients are more likely to have poor outcomes.” So the report said that there was “significantly worse” performance at Queen’s hospital, yet the Government are still planning the closure of the A and E at King George hospital, even though they know that Queen’s hospital has been failing, is failing and will continue to fail unless massive investment is made there, and that the King George is the better performing of the two hospitals in the trust. My constituency has a very young population with a large number of children. Some 30% of the people who go to A and E at the two hospitals in my local trust are children, yet the children in my constituency will have to move, with their parents, to the Queen’s hospital to attend A and E, rather than be treated in the better performing of the two hospitals in this failing trust. The CQC report is absolutely damning. It points out: “The trust faces significant difficulties in recruiting medical staff for A&E, and has done since 2011.” Of course, October 2011 was when the Government decided that King George hospital would be run down and that this trust would have only one hospital in around two years. I do not think that date is a coincidence. The reality is that there is a damaging impact on morale and on the future of the services in my borough and the neighbouring ones as a result of this decision. The report also states: “The College of Emergency Medicine recommends that, for the number of patients seen in the A&E at Queen’s Hospital, it should have 16 consultants to provide cover 16 hours a day, seven days a week.” A separate part of the report reveals that about 10 consultants would be needed at King George hospital, yet: “The trust has eight consultants in post out of an establishment of 21 to cover both A&E departments at Queen’s and King George Hospitals. The heavy reliance on locum staff is putting patients at risk of receiving suboptimal care. Joint work with other trusts has not achieved the desired results and additional work is underway, including recruiting staff from overseas.” Will the Daily Mail, the Daily Express, the UK Independence party and Ministers please note that the 9 Jan 2014 : Column 556 suggestion is to recruit staff from overseas to deal with the crisis caused by a lack of consultants in NHS trusts in north-east London? The report criticises the inadequate record-keeping. It talks about the need for significant management improvements. I do not have time in this short Adjournment debate to go into the great detail that is in the report, but I will say that there are hard-working and dedicated members of staff and good practice in some departments in the trust. I must declare an interest. This week, I was an out-patient in the ear, nose and throat department at King George hospital. I was seen quickly and before my appointment time and I was dealt with in an efficient manner. I want to place it on the record that the morale of the staff in the two hospitals remains remarkably high, but they are to some extent lions led by donkeys. They are suffering from years, perhaps decades, of problems in the health service in north-east London. I have been an MP for 21 years and have seen a succession of chief executives and significant reorganisations, and yet the fundamental problem is that the trust has a deficit of £100 million, which is clearly one of the driving forces in the reorganisation, and, at the same time, it has a massive catchment area of between 700,000 and 800,000 people. It is one of the largest trusts in the country with a huge, diverse population, a lot of churn and movement of people, and, as a result, some inadequate GP and primary care services and problems at the A and E. The fundamental issues are not being solved by whatever reorganisation is happening. Let me make a few more remarks before the Minister responds. The report says: “There was widespread concern from staff that the trust has not fully supported the A&E” when concerns were raised. One member of staff said: “We never see any of the management over here and all the important meetings are held at Queen’s.” The larger of the two hospitals, the hospital built for 90,000, now has 140,000 admissions in a year. The report went on to say: “The staff also felt that they were not kept up to date on the planned closure of the A&E at King George Hospital by senior management in the trust. One nurse told us, ‘There is a lot of unrest about the closure; we feel they are doing it by the back door. It makes it more difficult to recruit and keep staff.’” The problems we face at the King George and Queen’s hospitals cannot be resolved even by a change of management. I understand that the current chief executive has indicated that she will be leaving in a couple of months. Having been involved in the reorganisation and running down of Chase Farm, she has now done her job at King George hospital and will no doubt be moving on to some other unfortunate trust. I also understand, although it is not yet quantified, that there will be some form of special new management structure and things associated with special measures. Perhaps the Minister can clarify what special measures mean as regards the day-to-day running of the organisation. Will there be additional financial support? Will there be additional resources? The Barking, Havering and Redbridge clinical strategy document—I have the presentation for stakeholders, patients and the public in my hand, as well as the document itself—contains interesting phrases. For example, it says that areas of 9 Jan 2014 : Column 557 King George hospital will be “liberated” for use by other services and facilities. I thought when I read that that it was some sort of Maoist cult trying to have a people’s liberation army of consultants and NHS bureaucrats coming in to seize the stable base areas in the centre of my constituency. The NHS bureaucracy’s jargon sometimes amazes me. What is being talked about is running down services in Ilford and transferring facilities out of other buildings in the borough or elsewhere that will then be sold off, presumably for use as housing to add to the population demanding services from the trust while the total number of beds is run down drastically from 1,250 to about 800 to 900. King George hospital serves a population that includes some of the poorest people in north-east London. I worry about the long-term implications. We were told—this has been repeated in various trust documents—that the original plan was to wait for about two years, until new facilities had been established at Queen’s hospital, for the A and E at King George to be run down. That has obviously slipped, as we are now two and a half years on. I was told informally a few months ago that they were talking about the end of 2014 to the early part of 2015, yet the clinical strategy reveals that the new facilities at Queen’s hospital will not be ready until the middle or the autumn of 2015. One document says that the plan is to: “Move all emergency medicine and surgery to Queen’s Hospital by mid 2015”, whereas another says that that will be done by early 2016. The whole process is still uncertain. Given the uncertainties, the problems, the management issues that have arisen and the poor morale of the staff, there should be a moratorium with a review. My ideal solution would be to go back to having a trust that would run the hospital in Ilford—the better performing of the two A and Es—and keep an accident and emergency department in Redbridge, as we have had since 1931. That would mean that the people of my borough, which at that time had a population of 85,000, would today, with a population approaching 300,000, have a hospital to serve them when they need it to meet their emergency needs. I hope that the Government will seriously reconsider the situation, given the unprecedented action of the CQC—this is the first time an NHS trust has been put into special measures in this way—recognise the serious problems and recognise the dysfunctional nature of the Barking, Havering and Redbridge trust. 5.19 pm The Parliamentary Under-Secretary of State for Health (Jane Ellison): I congratulate the hon. Member for Ilford South (Mike Gapes) on securing the debate. I have heard him raise this issue in the House before, and it is clearly one of enormous interest and importance to his constituents. Like him, I wish to pay tribute to NHS staff in his area, particularly in the trust, as it has faced significant financial and performance challenges over recent years, as he outlined, including substantial problems with recruitment and retention. It is therefore particularly important to pay tribute to those front-line staff who have endeavoured—with some success, it sounds—to 9 Jan 2014 : Column 558 deliver an acceptable level of patient care in the face of a difficult situation. We thank and pay tribute to them for that. I do not have a huge amount of time, so will give an undertaking now to get in touch with the hon. Gentleman after the debate if there are any issues that I cannot respond to or that I have not picked up on. It is worth saying—he will be disappointed, but it is better to say it straight away—that there has been no change in the position on the reconfiguration plans as laid out by the Secretary of State in the most recent official correspondence. I will therefore focus my remarks on the special measures situation and some of his questions about it, as I have some more detailed information to put across. As we have heard, the NHS Trust Development Authority has decided to place the trust in special measures. The decision was not taken lightly; it follows the findings of an inspection by the Care Quality Commission’s chief inspector of hospitals, which demonstrated unacceptable failings in the trust. The chief inspector acknowledged that the trust has demonstrated improvements in some areas, such as the maternity service, but that good work has not been replicated throughout the trust. He highlighted that long-standing difficulties in the two A and E departments are clearly affecting patients and that attempts by the trust to address the problems have not had the hoped-for impact. I share the hon. Gentleman’s disappointment that the much-needed improvements to A and E have not been achieved. All our constituents—I am a fellow London Member—deserve the best health care that we can provide. I recognise his characterisation of the local catchment area, as I see many of the same characteristics in my constituency. London is an extremely challenging health economy. The city’s diversity brings both exciting challenges and big pressures, so I understand what he is alluding to. Those are some of the reasons why the chief inspector recommended that the trust should be placed in special measures, whereby the trust’s leadership can get the support it needs to tackle the scale of the problems it faces. Special measures provide an open and transparent way for the trust to take swift action to improve the quality of the services it provides for local people, which is what we want to see. I have been informed that the TDA has set out an intensive and focused programme of support. It includes the development of an improvement plan by the trust, which the TDA expects to see implemented over the next 12 months, and the appointment of an improvement director to support the development and delivery of the trust’s improvement plan. I recognise that the hon. Gentleman feels that he has seen people come and go with that objective in mind, but clearly it is extremely important that the improvement director is appointed, grasps the situation and makes a real difference. There will also be a review of the capability of the trust’s board and senior management team, to be undertaken this month by Sir Ian Carruthers. It aims to ensure that the organisation has the capacity and capability to respond to the chief inspector’s report and deliver the improvement plan. I hope that it will report very soon after this month’s assessment so that it can be one of the building blocks on which the trust can move forward. The trust’s plan will also need to identify the support it needs from partner organisations to improve services, including its commissioners and local authorities. I 9 Jan 2014 : Column 559 understand that the relationships are not as good as they could be and that there have been problems for some time. Work is already under way to identify partners to support the trust in recruiting and retaining staff. I recognise that the figures on vacancies that the hon. Gentleman set out, particularly for A and E, which were given to me in the briefing for this debate, are not acceptable. That is a real challenge, and one that the trust needs to respond to. I can reassure the House that the trust’s plan will be published on the NHS Choices website and will be freely available to the public. We also expect regular updates to demonstrate how the trust is progressing. I believe that progress will be posted against that plan in a transparent way as the period for improvement progresses. The TDA will keep close to the trust as it works to make the necessary improvements and will hold board-to-board meetings with the trust. It has also arranged to buddy-up and provide support, as appropriate, with a high-performing foundation trust. Special measures are designed to produce results quickly. The trust will have one year to improve sufficiently, as judged by the chief inspector of hospitals, in order to exit special measures. As the hon. Gentleman said, the safety of A and E departments is very important. The trust has been subject to an external clinical review of the safety of its A and E services commissioned by the local clinical commissioning groups and undertaken by the London Clinical Senate. I understand that this was in response to a request from local CCGs following concerns raised about potentially unsafe levels of medical staffing within the A and E units, as we have discussed. The TDA has confirmed to me that this review, which published interim findings in September 2013, concluded that neither the A and E at King George hospital nor the A and E at Queen’s hospital was unsafe, but it made a number of recommendations to improve the service. It has also been made clear to me that the A and E review was very much independent of the chief inspector of hospitals’ inspections at the trust and the TDA’s decision to put the trust into special measures. Let me touch on some of the support that has been put in for A and E. We have provided further support to the trust through the funds available to respond to winter pressures. The local health economy in the hon. Gentleman’s area has received about £7 million, while the trust itself has received £3 million. Some £4 million 9 Jan 2014 : Column 560 has been earmarked for A and E recruitment, and another £4 million was allocated throughout the local health economy by the urgent care working group responsible for the area. That money was allocated based on clinical need and went to a range of organisations, including the local mental health trust, the London ambulance service, and the local authority. There is no time to talk about this in detail now, but the Government are taking longer-term action with regard to reducing demand at A and Es. Some of that falls within my own portfolio of public health in seeing what health and wellbeing boards can do to reduce demand as regards people going to A and E when that is not the appropriate place for them to be. Of course, the extension of GPs’ opening hours through new contractual arrangements is highly relevant in a population that is, as the hon. Gentleman described, to a large extent young, highly mobile, highly diverse, and often working in London’s 24-hour economy. I strongly recommend that the hon. Gentleman and other hon. Members on both sides of the House who have expressed concern about the situation for some time should continue to engage with the trust at every opportunity—clearly, there have sometimes been challenges in the relationship—and with their local health and wellbeing board. The challenges facing the trust cannot be tackled alone and will best be tackled by the local NHS and all the partners—local authorities and so on—working together. It is absolutely vital to get that right. The priority now is to make sure that the trust is able rapidly to improve the care that it provides to the hon. Gentleman’s constituents. The TDA will work closely with the trust to help it to improve and will take every necessary action to make sure that the issues raised in the chief inspector’s report are addressed. I will meet the London team within NHS England shortly. I will raise the issues highlighted in this debate, among others, and I will continue to keep the hon. Gentleman and other hon. Members who are interested in the situation informed as we go through this important year for his local NHS. Question put and agreed to. 5.28 pm House adjourned. ________________________________________

At BHRUT Board meeting

Save King George Hospital activists turned up at the BHRUT board meeting earlier today. The photo was taken outside Queens before the meeting started.

Inside the meeting Board papers were available which showed the Queens A&E four hour waits had dipped below 80% at times last year. The latest bed occupancy figure given for King George and Queens combined was 95% .

The Care Care Commission states in their December 2013 report regarding King George Hospital

 "Once bed occupancy rates rise above 85%, quality of patient care can be affected"

 Averil Dongworth, the BHRUT chief Executive was asked in light of these statistics whether the plan to close King George Hospital A&E in 2015 was still going ahead. Averil said the closure plan is continuing.

The campaign to ditch these potentially dangerous proposals must go on.

Come to the photoshoot tomorrow at Queens 12:30pm

There is a Save KGH photoshoot tomorrow, Wednesday 8th January 12:30pm outside Queens Hospital ahead the BHRUT board meeting in Queens hospital at 1pm. The purpose is to call for the board to accept that a key part of the recovery plan to get our hospitals safe and out of special measures must be the abandonment of the plan to close KGH A&E.