Tuesday, 16 June 2015

North West London Commission on Health: Initial Report

Excellent report, published on 26 March 2015, contains the initial findings of the independent commission chaired by Michael Mansfield QC. For those of you who may not have the time to read the 119 page report, I have tried to summarise and highlight the findings which constitute a review of ‘Shaping a Healthier Future’ (SaHF).

A McKinsey and Company report to Government in 2009 proffered the view that the NHS spends too much money on acute care and that £billions could be saved by shifting care from acute hospital settings. NHS boss Nicholson demanded £20 billion savings on NHS costs across England.
Out of this came the approach in NHS North West London to save one £billion by 2015 by downgrading four of the nine major hospitals, move expensive acute hospital care into cheaper Out of Hospital (OOH) services and primary care, and centralise services at five major hospitals.

The decision to downgrade four major hospitals – and close four hospital A&E units – was taken before any public consultation was undertaken. The report is critical of the consultation as it simplistically asked residents which hospital they wanted downgraded.

SaHF offers poor access to care especially for those living in deprived areas. A formal needs assessment for the 1.9 million population is missing from SaHF. What is evident is that SaHF supplied a set of assumptions about what reductions in demand were needed for all SaHF’s pre-determined capacity reductions to work.

A&E Capacity and Performance
SaHF claimed that North West London is overprovided with A&E units. The commission could find no data to back up this claim. Authoritive data from multiple sources shows that by reducing A&Es from nine to five would create loadings on the surviving A&Es which would be 50% more than the national average.

In North West London over the last four years A&E attendance fell by 26.2 %. Urgent Care Centre usage seems to be the explanation here. A&E performance in North West London deteriorated since the closure of the A&Es at Hammersmith and Central Middlesex hospitals in September 2014. Type-1 (the most ill patients) performance is the most concerning. For some weeks performance was the worst in England. SaHF is in denial about A&E closures being responsible for this disastrous performance. SaHF refused to release a report on the subject produced by McKinseys.

OOH Care
SaHF proposed to transform OOH care – spending up to £310 million over five years. All eight Clinical Commissioning Groups (CCGs) provided detailed plans on what they would achieve by March 2015. However there is very little to show what has been achieved by March 2015.

SaHF claims there is excess capacity, but it is unclear whether the growth in population has been sufficiently factored into calculations of the number of beds required.


SaHF is all for specialisation and centralisation of services. It favours big hospitals. However the commission could find no recent evidence which supports the case for centralisation of acute services.

SaHF’s reason for reducing the number of maternity units is difficulty in recruiting and retaining consultants and midwives at each of the seven sites. SaHF also claims it’s uneconomic to retain Ealing Hospital’s maternity unit. However a detailed financial analysis to back up this claim is not avaialable from SaHF.

Emergency Services
Lots of published papers quoted here refuting SaHF’s claims for centralisation of services and closure of four A&Es. The commission’s findings are that a much stronger case should have been put forward to justify the closure of one A&E unit – never mind four!

The evidence on the impact of OOH services on the demand for acute services does not support the conclusion that five acute units will be able to support the needs of 1.9 million people.

Financial considerations are the ultimate driver for SaHF. This section of the report examines the unproven results of OOH expansion, the affordability, risks, uncertainties and deliverability of the SaHF programme. It questions whether the SaHF costs are under control, whether double –counting is going on in SaHF, and whether too little is being spent on our healthcare anyway.

SaHF cost £62.9 million in 2013/14, yet NHS NW London enjoyed a cash surplus of £100.1 million. In 2014/15 figures are more difficult to source but an overall loss of £14.9 for NHS NWL is identified. (The overall cost of SaHF (2010/11 to 2017/18 ) is projected to be £235.5 million of which £35.43 million is for management consultancy).
NHS NWL is apparently in overall balance so why there were two A&E closures in September 2014? This was at a time when it had not been proven that SaHF plans were affordable, deliverable or financed.

QIPP and SaHF Entanglement
Possible double counting of cost savings revolve around the NHS Quality, Innovation, Productivity and Prevention ( QIPP) programme and SaHF. QIPP may have already succeeded in making the savings needed without recourse to SaHF closures. The Commission thinks it unlikely that QIPP or SaHF programmes will meet the 44.5% savings required by 2020. SaHF’s refusal to release its latest business case makes it impossible to unravel SaHF (and QIPP) projections and savings.

Should More Be Spent on Healthcare?
Whether you choose money, nurses, doctors or beds as your yardstick the UK has lower numbers than Germany, France and USA. But McKinsey in 2009 told the Government that the UK had high hospital costs and utilisation costs.

Financial Benefits of SaHF
In 2012 annual savings by implementing  SaHF of £135 million were stated. However the commission has been told that the capital costs have been significantly underestimated as has population growth. Annual savings might be significantly lower that £135 and might render SaHF plans unaffordable.

Investment in OOH
The creation of new and enhanced OOH services should precede any reconfiguration of acute services. There is no evidence of these new or enhanced services. There is no evidence that there are large reductions in acute capacity as a result of extensions to OOH services.

As well as investing £250 million in OOH services, SaHF needs £750 invested in acute services. Can NHS NWL afford this? Only a review of the latest SaHF business case might provide clues to this.

The report questions whether the SaHF is deliverable. It questions who owns the project – the NHS Commissioning Board, local CCGs or key local providers? The fact that the programme director has changed several times is not a positive sign. The report highlights many risks – service planning, safety, quality, business interruption, estates and construction, delay and adverse publicity.

The report proposes that SaHF develop a more conservative ‘Do Minimum’ option which would be easier to finance and easier to manage.

Framing the Problem
SaHF came into being during a period of great turbulence in the NHS nationally, regionally and locally. The North West London Strategic Health Authority and Primary Care Trusts were being abolished. CCGs were being created and many hospitals were wrestling with trying to attain Foundation Trust status. There was therefore no stable strategic platform to plan major changes in service delivery.

The report cites the failure of the ‘Better Services Better Value 2011’ project in South West London. With many similarities to SaHF the project was abandoned in the face of its unsustainability. The commissioners predict a similar fate for SaHF.

Diagnosing the Problem
SaHF is based on assertions. These assertions include that only five major hospitals are affordable in North West London and that the need to improve quality of primary care implies there should be a reduction in acute capacity. However the SaHF strategy should have been based on local needs’ assessments, a deep analysis of the nature of the problems and detailed research on costs in the current system.

SaHF Objectives
Not  clearly stated or followed. Why choose A&E services for reconfiguration-based quality improvement? A&E represents a small percentage of healthcare spending. Quality improvements could be made which would not involve a major reconfiguration and a capital spend on £1 billion.

The Options Appraisal Process
The commissioners believe too few options were considered by SaHF. Critically a ‘Do Minimum’ option was not considered. This breaks Treasury guidelines and its absence could lead to SaHF failing to gain Treasury approval.

Public Consultation
The public in 2012 were not presented with an approved business case.(In fact an approved business case still does not exist). Current plans are much more expensive and the benefits much less that those initially proposed to the public in 2012.

Local Authorities Ignored
Local authorities have been starved of information and involvement. It’s clear that they have developed doubts as to whether SaHF can deliver what it has promised.

The commissioners want the whole SaHF programme to be halted and independent reviews to take place on the September 2014 A&E closures and the planned A&E closures at Charing Cross and Ealing Hospitals. They want the assertion that OOH services can effectively substitute for acute capacity and save money to be reviewed. When the new business case emerges if it is significantly different from the one presented to the public in 2012 then a new public consultation exercise must be mounted.

Eric Leach
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