Redbridge CCG reply to Questions

Thank you to Redbridge Clinical Commissioning Group for providing the below

Oral questions from Cllr Andy Walker


Q: The CCG will be asked to seek an explanation from BHRUT as to why bed occupancy at Queens is 94% and 79% at KGH as CQC recommend a safe level of 85%.
A: In terms of high bed occupancy at Queen's, it's simple - too many people are being admitted to the hospital and those that are in there stay too long.
We launched two new services to Redbridge in November that are already having an impact on this - the Community Treatment Team and Intensive Rehab service - which help prevent admissions and also help get people home sooner. At the moment the CTT team at the hospital is able to treat and prevent around 60 people a week from being admitted. CTT teams in the community are currently treating and preventing more than 130 people a week from ending up in hospital. We've also reduced the time it takes to move people from a hospital to a community bed from 5 to 2 days.
The CCG and our health and social care partners are working in partnership to improve the integration of care so that people spend less time in hospital. The Trust is starting seven day working and a new joint discharge team will launch soon. Our draft 5 year strategic plan, which goes to NHSE in April, includes an objective to reduce avoidable time in hospital through integrating care by 13%.

The work we are doing on this with our health and social care partners has seen a reduction in admissions of 15% in the past 12 months and a reduction in A&E attendances of 5.67%.

Q: BHRUT is unable to provide waiting list figures for technical reasons and the CCG will be asked about this too.

A: This is caused by problems associated with the Trust's change of IT patient administration
system which means the Trust doesn't have access to accurate data and therefore isn't able to report waiting times at the moment.

This is a serious issue and the trust is working with the Trust Development Authority and our CCGs to help establish an interim solution while the IT issues are resolved.



Q: Cllr Walker will also call on the CCG to 'scrap the plan to close A&E at KGH in 2015'.

A: The plans to reconfigure services were signed off by the secretary of state for health in 2011, following a lengthy public consultation and an independent review by a panel of experts. Our job is to work with the hospitals Trust and other partners to implement those proposals safely and improve health outcomes for local people.

Centralising A&E services on one site will enable BHRUT to provide a safe, high quality A&E service. At the moment the service is stretched across two sites and the CQC identified that at times it may be unsafe because of this (e.g. staffing issues). We can't leave things as they are - it's not an option.

That's why we are looking at improving the entire urgent care pathway so that patients can be seen in the right place, more quickly, by the right teams with the right expertise and leading to better outcomes and shorter waiting times. Most people who go to KGH A&E now will still be seen there by an improved 24/7 Urgent Care Centre.

Last year we centralised maternity services and it has given us a safer, higher quality service for Redbridge women. That's what we plan for A&E.



Oral question from Cllr McGeary


Q: The improvements required by the Health for NEL proposals to A & E are likely to cost £50 million through the PFI route and are, as the trust says, unaffordable. How can the BHRUT say that they will still close King George A & E by December 2015 and still comply with the Secretary of State's statement that the reconfiguration changes will not happen until the health for NEL improvements have been made.

A: We've been very clear all along that changes to A&E services - just like maternity last year - cannot happen until it is safe to do so. That won't change. One result of the Trust being placed in special measures is that the new leadership is producing an Improvement Plan that will not only demonstrate how they will make the very necessary improvements to safety and quality of services, but will also show how they align this with the reconfiguration proposals.

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Photo from today outside Redbridge Clinical Commissioning Group

 

 

 

 

 

 

 

Thanks to Bob Archer for photo

 

 

Thanks to Councillors Fairley-Churchill and McGeary and Redbridge residents for attending.

 

The GPs made everyone welcome who wanted to speak, going out of their way to accommodate people by changing the agenda to let the public speak first to allow people to go after asking their questions rather than wait to the end of the meeting.

 

Valarie, a Redbridge resident made a passionate speech about how important King George Hospital is, her oratory drew a round of applause.

 

While no ground given by GPs on KGH A&E closure issue, GPs did appear to be concerned by the high bed occupancy rate at Queens hospital. This is an issue that needs to be kept under scrutiny as the CQC mentions a safe level of 85% and Queens was at 94% on March 16th.

 

GPs also appear concerned by BHRUT inability to provide waiting list figures. The responses to questions were detailed and I hope to be able to produce a note from the CCG of what was said in due course.

 

It is welcome that GPs are willing to have a dialogue with the public about the proposed closure of KGH A&E.

 

 

 

 

 

 

 

 

 

 



Photoshoot 12:30 Thursday 27th March Becketts House

There will be a photoshoot at 12:30pm outside Becketts House on Ilford Hill on Thursday 27 March before the Redbridge Clinical Commissioning Group meets.

The purpose is to call on the CCG to scrap the plan to close KGH A&E in 2015.

The CCG will be asked to seek an explanation from BHRUT as to why bed occupancy at Queens is 94% and 79% at KGH.

The CQC recommend a safe level of 85%.

BHRUT is unable to provide waiting list figures for technical reasons and the CCG will be asked about this too.

A Recorder photographer has been booked.

As the Chair of BHRUT resigns, there are As the Chair of BHRUT resigns, there are strong parallels with Mid-Staffs as the public, experts and local politicians are ignored by NHS authorities

Neil Zammett writes

 

The news last Friday 21^st February that Sir Peter Dixon has resigned as Chair of BHRUT the trust that runs Queen’s and King George is a body blow to local services and management alike.

As a former Chair of the Housing Corporation, University College Hospital and Enfield and Haringey Health Authority Sir Peter is a highly regarded and experienced public servant whose presence at BHRUT gave a calibre of leadership which it would be hard to match.

He of course follows a similarly distinguished Chair, Sir David Varney, who left the Trust after only six months in June 2010, and joins the current medical director, finance director and chief executive in departing.

Only very recently Sir Peter was heard to say at a Scrutiny meeting that he was in it “for the long term” so something significant has happened to prompt his departure.

The answer to this lies in the complex relationship between the Care Quality Commission (CQC), NHS England and a shadowy body called the National Trust Development Agency (NTDA).

The CQC ‘s last report on BHRUT made it clear that they had ran out of patience with the Trust’s inability to solve the local crisis in A&E; a crisis that had lasted for three years, not just days or months.

The NTDA, who effectively act for the Department of Health, were faced with a recommendation from CQC to put the Trust into “special measures”; they had to comply and this started the current sequence of events.

Reading between the lines it is clear that no one had worked out what “special measures” actually meant in this case. It was so unclear that the NTDA despatched an NHS grandee, Sir Ian Carruthers to the Trust to assess the situation after they had made the announcement.

But before special measures Sir Peter had already presented his assessment independently to the NTDA backed up by management consultant’s report. Again we do not know the detail but an important part of this assessment must have been a need for resources and capacity.

We can imagine that the report would have said something along the lines that: “Without the ability to source adequate capacity to support both management and clinical staff, these hospitals will continue to fail.”

Obviously Sir Peter’s arguments fell on deaf ears.

The Future

Whatever else this sad turn of events has meant it is clear that the Health4NEL plan to close A&E at King George has now run its course. There is no doubt that the management of BHRUT have done their best but the colossal projected overspend for 2013-14, the continuing dreadful performance of A&E and the departure of all the key staff all point to the same conclusion-it is simply not possible.

Even Professor Sir Mike Richards the head of the CQC has gone on record about the huge challenge facing BHRUT which he later described as “A task like Everest”.

The recently appointed turnaround director and the interim finance director are both veterans of the South London Trust and the administration regime while the new “interim” Chair Dr Maureen Dalziel has only been given a three month contract. This would run out at the end of May, around the time of the local elections.

All of this suggests that Queen’s and King George are being lined up for administration by the NTDA and local CCGs, the GP organisations that now commission hospital services. The timing of the new Chair’s contract suggests that a formal announcement will be delayed until a politically less sensitive time.

Administration carries substantial extra risks. There are already indications that the recruitment of clinical staff is being adversely affected by the “special measures” and managers are obviously not going to be rushing to join the Trust. Morale at all levels must be at an all time low. Administration would accelerate this process and could lead to “recruitment blight” as has happened at Mid-Staffs.

More serious is the fundamental difference of view between a very senior and experienced public servant like Sir Peter and the NTDA. This cannot be dismissed as a simple personality clash given the history outlined above and goes to the heart of the continuing problems at BHRUT:

· On the one hand, the NTDA, the CCGs and the Urgent Care Board (UCB) are still backing the Health4NEL plan

· On the other Sir Peter, Redbridge Council and this Blog see the need for more capacity and resources.

Without a consensus on how to move the Trust forward local people face a long period of uncertainty with failing services and an emerging crisis of confidence and leadership.

It’s just like Mid-Staffs

When things go wrong in the NHS it is difficult to find out who is responsible. At Mid-Staffs two enquiries and two massive reports gave us some clues and some recommendations about stopping this happening again. There are close parallels between Mid-Staffs and BHRUT.

In both cases, a major problem was the single minded pursuit of management objectives at the expense of patient care. At Mid-Staffs it was foundation trust status; at BHRUT it is the closure of A&E at King George.

At Mid-Staffs expert opinion from Professor Brian Jarman was disregarded; at BHRUT it is Sir Peter’s and Sir David’s from a management perspective and the evidence from this Blog from an analytical one.

Finally there are the views of the public and local politicians; again comprehensively ignored, just like Mid -Staffs. I am not suggesting the consequences are on a comparable scale but local people have had to endure a dreadful A&E service and Redbridge women have been forced against their wishes to use a sub-standard maternity service at Whipps Cross.

Who is responsible?

Although the NHS reorganisation means that many of the decision making bodies have gone, the NTDA as the controlling successor body is primarily responsible.

But the CCGs and the Urgent Care Board (UCB) although they are in a less controlling role still bear a heavy responsibility for what is happening. Without their support the NTDA could not continue with the closure plan. Surrey Downs CCG in South London has done just that; pulling out of the equivalent plan to downgrade Epsom and St Helier Hospitals.

Finally the CQC, while precipitating the current management crisis, has very little authority to influence plans as such, illustrating the weakness of accountability and regulation in market economies.

What needs to happen?

At the heart of this is the need to scrap the Health4NEL plan. It clearly has not worked, there is overwhelming evidence now that the assumptions underlying it were deeply flawed and continued efforts to implement it have created the present crisis.

Making this decision is primarily the responsibility of the NTDA. Redbridge CCG could take the lead on this, however by following the example of Surrey Downs and withdrawing from the plan. It’s up to them.

Local people need to be involved not pushed to the margins. They are supposed to be at the centre of what the NHS does, but locally their voice has been systematically ignored. The same is true for local politicians. The CCGs and the UCB need to open up and start listening to their views.

In particular there needs to be a critical review of the schemes the UCB has funded this winter and their impact on A&E performance. A central question is why the UCB has not opened up more beds to ease the pressure on A&E. This is what has precipitated the crisis.

Finally there is the issue of ignoring expert advice. There is a sense in some quarters that the NTDA and others are knowingly pushing BHRUT over the edge for whatever reasons. This is a potential charge they should be given an opportunity to answer in a way which makes them publicly accountable.

The news on Friday 21^st February that Sir Peter Dixon has resigned as Chair of BHRUT the trust that runs Queen’s and King George is a body blow to local services and management alike.

As a former Chair of the Housing Corporation, University College Hospital and Enfield and Haringey Health Authority Sir Peter is a highly regarded and experienced public servant whose presence at BHRUT gave a calibre of leadership which it would be hard to match.

He of course follows a similarly distinguished Chair, Sir David Varney, who left the Trust after only six months in June 2010, and joins the current medical director, finance director and chief executive in departing.

Only very recently Sir Peter was heard to say at a Scrutiny meeting that he was in it “for the long term” so something significant has happened to prompt his departure.

The answer to this lies in the complex relationship between the Care Quality Commission (CQC), NHS England and a shadowy body called the National Trust Development Agency (NTDA).

The CQC ‘s last report on BHRUT made it clear that they had ran out of patience with the Trust’s inability to solve the local crisis in A&E; a crisis that had lasted for three years, not just days or months.

The NTDA, who effectively act for the Department of Health, were faced with a recommendation from CQC to put the Trust into “special measures”; they had to comply and this started the current sequence of events.

Reading between the lines it is clear that no one had worked out what “special measures” actually meant in this case. It was so unclear that the NTDA despatched an NHS grandee, Sir Ian Carruthers to the Trust to assess the situation after they had made the announcement.

But before special measures Sir Peter had already presented his assessment independently to the NTDA backed up by management consultant’s report. Again we do not know the detail but an important part of this assessment must have been a need for resources and capacity.

We can imagine that the report would have said something along the lines that: “Without the ability to source adequate capacity to support both management and clinical staff, these hospitals will continue to fail.”

Obviously Sir Peter’s arguments fell on deaf ears.

The Future

Whatever else this sad turn of events has meant it is clear that the Health4NEL plan to close A&E at King George has now run its course. There is no doubt that the management of BHRUT have done their best but the colossal projected overspend for 2013-14, the continuing dreadful performance of A&E and the departure of all the key staff all point to the same conclusion-it is simply not possible.

Even Professor Sir Mike Richards the head of the CQC has gone on record about the huge challenge facing BHRUT which he later described as “A task like Everest”.

The recently appointed turnaround director and the interim finance director are both veterans of the South London Trust and the administration regime while the new “interim” Chair Dr Maureen Dalziel has only been given a three month contract. This would run out at the end of May, around the time of the local elections.

All of this suggests that Queen’s and King George are being lined up for administration by the NTDA and local CCGs, the GP organisations that now commission hospital services. The timing of the new Chair’s contract suggests that a formal announcement will be delayed until a politically less sensitive time.

Administration carries substantial extra risks. There are already indications that the recruitment of clinical staff is being adversely affected by the “special measures” and managers are obviously not going to be rushing to join the Trust. Morale at all levels must be at an all time low. Administration would accelerate this process and could lead to “recruitment blight” as has happened at Mid-Staffs.

More serious is the fundamental difference of view between a very senior and experienced public servant like Sir Peter and the NTDA. This cannot be dismissed as a simple personality clash given the history outlined above and goes to the heart of the continuing problems at BHRUT:

· On the one hand, the NTDA, the CCGs and the Urgent Care Board (UCB) are still backing the Health4NEL plan

· On the other Sir Peter, Redbridge Council and this Blog see the need for more capacity and resources.

Without a consensus on how to move the Trust forward local people face a long period of uncertainty with failing services and an emerging crisis of confidence and leadership.

It’s just like Mid-Staffs

When things go wrong in the NHS it is difficult to find out who is responsible. At Mid-Staffs two enquiries and two massive reports gave us some clues and some recommendations about stopping this happening again. There are close parallels between Mid-Staffs and BHRUT.

In both cases, a major problem was the single minded pursuit of management objectives at the expense of patient care. At Mid-Staffs it was foundation trust status; at BHRUT it is the closure of A&E at King George.

At Mid-Staffs expert opinion from Professor Brian Jarman was disregarded; at BHRUT it is Sir Peter’s and Sir David’s from a management perspective and the evidence from this Blog from an analytical one.

Finally there are the views of the public and local politicians; again comprehensively ignored, just like Mid -Staffs. I am not suggesting the consequences are on a comparable scale but local people have had to endure a dreadful A&E service and Redbridge women have been forced against their wishes to use a sub-standard maternity service at Whipps Cross.

Who is responsible?

Although the NHS reorganisation means that many of the decision making bodies have gone, the NTDA as the controlling successor body is primarily responsible.

But the CCGs and the Urgent Care Board (UCB) although they are in a less controlling role still bear a heavy responsibility for what is happening. Without their support the NTDA could not continue with the closure plan. Surrey Downs CCG in South London has done just that; pulling out of the equivalent plan to downgrade Epsom and St Helier Hospitals.

Finally the CQC, while precipitating the current management crisis, has very little authority to influence plans as such, illustrating the weakness of accountability and regulation in market economies.

What needs to happen?

At the heart of this is the need to scrap the Health4NEL plan. It clearly has not worked, there is overwhelming evidence now that the assumptions underlying it were deeply flawed and continued efforts to implement it have created the present crisis.

Making this decision is primarily the responsibility of the NTDA. Redbridge CCG could take the lead on this, however by following the example of Surrey Downs and withdrawing from the plan. It’s up to them.

Local people need to be involved not pushed to the margins. They are supposed to be at the centre of what the NHS does, but locally their voice has been systematically ignored. The same is true for local politicians. The CCGs and the UCB need to open up and start listening to their views.

In particular there needs to be a critical review of the schemes the UCB has funded this winter and their impact on A&E performance. A central question is why the UCB has not opened up more beds to ease the pressure on A&E. This is what has precipitated the crisis.

Finally there is the issue of ignoring expert advice. There is a sense in some quarters that the NTDA and others are knowingly pushing BHRUT over the edge for whatever reasons. This is a potential charge they should be given an opportunity to answer in a way which makes them publicly accountable.

St Helier a lesson for Redbridge?

Thanks to Helen for pointing out developments in South London to me per the link below.

http://www.suttonguardian.co.uk/archive/2014/02/18/11018889.Improvements_to_Croydon_s_A_E_face_delays_after_multi_million_pound_review_scrapped/


The report says

"The preferred option for health bosses involved in the review was for St Helier and Epsom Hospital to lose their A&E and maternity departments and the equivalent departments at Croydon, St George's and Kingston to expand by 2017-18.
But the plans are now off the table, at least until new recommendations are published in June"

This suggests Redbridge CCG, working with other local CCGs could sink the plan to close King George Hospital A&E. Will Redbridge Council be lobbying the Redbridge Clinical Commissioning Group over this?

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.