Take a case of a rapidly expanding population and the rapid shrinking of essential services...
Saturday 21st March marked the half way point of the Michael Mansfield Health Commission investigation into the so-called ‘Shaping a Healthier Future’ giant reconfiguration of the West and North West London hospitals infrastructure, which includes the seismic closure of 4 out of 9 A&Es – two of which have already bitten the dust before any other plans have been put in place, or indeed before the elusive business plan has been published.
This is all being done in contravention of the original NHS concept of universal healthcare in line with the needs of population.’ (Cllr Steve Cowan – Leader of Hammersmith & Fulham Council).
Just a few days earlier over 600 people had packed Hammersmith Town Hall to listen to a range of speakers share their passion for the need to Defend London's NHS
Witnesses to the People's Commission so far have included the leaders of both Councils and their cabinet members with responsibility for health; MPs Andy Slaughter and Stephen Pound (others were invited but declined ); campaigners from Save our Hospitals and Save our NHS; Tories with differing views from Hammersmith & Fulham and Kensington & Chelsea; hospital consultants; RCN & RCM spokespersons; patients and patient representatives – also local Healthwatch representatives.
The majority of witnesses at both sessions so far have offered a clear line of similar arguments and evidence – which is in part unsurprising, given that as the QC said on day one in Hammersmith Town Hall Council Chamber – ‘we have asked the local NHS to participate or at least respond on several occasions – but so far we have not had a proper reply’. This is a very different situation from the last inquiry, where the Lewisham People’s Commission, which included Baroness Mary Warnock and Blake Morrison along with Mansfield in the chair, heard evidence from Lewisham Hospital CEO, as well as from numerous consultants and nursing staff, also the CCG Chair.
Dr Mark Spencer’s name was repeated often – but in the context of ‘conflict not congruence’ ( Cllr Vivienne Lukey) - ‘Not one single Shaping a Healthier Future person could come out with access figures - evidently just plucking approximations out of the air and hoping for the best’
A series of chaotic approach descriptors emerged in both of the Hammersmith & Ealing Council Chambers......
‘There are too many known unknowns - but what is known is that other hospitals are operating to capacity’ said Hammersmith & Fulham Council Leader Steve Cowan
There appears to be an ‘awful lot of vested interest in not stirring up the public’– as evidenced by the poor advertising of ‘changes’ rather than closure ( which we have previously documented on here) as well as a consultation which witness after witness cited as being inadequate, ..........................
Andy Slaughter, MP for Hammersmith, said the whole plan was based upon flawed assumptions about population growth, The plans will result in the removal of 93% of inpatient beds in the borough and all consultant emergency medicine, including the hyper-acute stroke unit, intensive treatment, and type 1 accident and emergency.
‘Given that targets are regularly missed by wide margins and the pressure on staff and patients is intolerable - there is already insufficient capacity in the system..... It appears therefore that the sole benefits of SaHF are cost savings, or generating capital receipts by land disposal. ‘
Of course this will then result in a further population expansion ‘ we cannot believe they are about to close and downgrade when the population is growing so fast!’ said one witness. In particular, developments in Old Oak Common & Earls Court constitute the largest property expansions in Europe – and there are many are other new builds in the area, which could potentially see these shrinking services completely swamped.
A key question which also remains unanswered : Who will fund out of hospital care?
Consultation :
With the odd Tory exception, the overarching consensus was that the extremely costly McKinsey consultation was to say the least faulty and inadequate.
Access and information ‘might have been done better – there was an insufficient information stream.’ is one of the more polite descriptors. Merrill Hammer, Chair of Save our Hospitals and her husband Jim, reported their own experience of the consultation.
'There was no space for proper public debate. A large number of the population thought that the outcome had been ‘pretty much pre-decided. Options were closed. Minority ethnic groups under-represented – partly because it was very badly advertised. Staff on the door had no idea re nature of a key meeting. The CQC meeting was much better run.’
Jim reported ‘The planned reduction to 24 beds has been accompanied by no answers to any questions. No one responds! It is impossible to work out who is in charge...!!’
Whilst CCG Chair Spicer has refused over a 2 year period to provide the evidence to back up all the plans whilst also declaring ‘Shaping a Healthier Future is not about reducing hosp beds!’ - that is clearly the case and it is also very clear that the retained services will be concentrated in the richer south.
‘ it cannot be said that due process has been followed in terms of establishing a case, or in terms of consulting with the public, a point which my constituents frequently mention to me. Despite SaHF affecting two million people in west London, most feel they have no ownership of the proposals and that their views are disregarded. ‘ Andy Slaughter MP
Tory-Flagship rump-man Andrew Brown took a different view and even on occasion seemed to disagree with himself. He cited 'working relationships in difficulties' between the Council and / Trust CCG, but when challenged to be specific he said it was 'not documented'. He felt it was unfair to be critical of NHS bodies and dived off the main points to cite the Imperial College Healthcare NHS Trust role in social care and the use of Better Care Fund (the insufficient to need programme which he referred to as a 'leading area') though struggled to explain the correlation with the dangers of uncertainty over A&Es.
Whilst saying he felt 'more could have been done' concerning the closure of Hammersmith A&E, Cllr Brown confessed that there was 'no way of knowing for certain' as to whether whatever eventually replaces Charing Cross A&E will be consult led or GP led - he also remarkably responded ' yes - in an ideal world' to Mansfield’s questioning about as to whether it was ‘remotely sensible’ to implement closures prior to there being anything in their place. Essentially his argument followed the line of a preference for there to be nothing, rather than provision which he maintained had been clinically unsafe!
(Fast-forward to Ealing a week later and we heard that the ‘unsafe’ mantra was possibly written on the back of an envelope in an unseemly bid to justify the closures after Cameron & Hunt began to voice concerns ....)
Cllr Brown also had ‘no idea’ about the huge losses in training and maintained that the Treasury would be organising the financing for the new builds, whilst showing great reluctance to discuss the unknown area of the large funding gap which has hitherto been predicated on a large scale asset strip of the Charing Cross site.
A revealing few minutes opening the lid on the mindset of the previous administration who had been responsible for the ideological drive-through of the chaos.
Interestingly, Cllr Robert Freeman of the Royal Borough of Kensington & Chelsea Conservative Group had a somewhat different take on matters from his Tory counterpart....
‘It was difficult - there was a certain expectation that the proposals would be okayed. My main concerns are how St Mary’s and Chelsea and Westminster will cope and also where the funding will come from to create the essential changes needed to cope with the additional burdens. There is great uncertainty that Imperial are not covering plans - they are not a strong trust financially and have pulled back from FT status’
Said Cllr Freeman - ‘we have to keep services open while works are done’
Cllr Rory Vaughan (LBHF Health Scrutiny Chair ) asked - ‘How is fragmentation going to work and how long will it take to re-educate the public?’
This is not simply a case of early teething troubles plus winter demand – the sharp downturn in performance at Northwick Park has remained, even since the much vaunted opening of a brand new A&E which seemingly has no more capacity than the old one.
Dr Spencer had famously said at an angry public meeting last year that anyone who was making their way to an A&E on the bus should instead stop off at a pharmacist, however in the real world, transport issues were a major concerns for almost all local witnesses.
Efficient transport routes and LAS priorities
So what preparations have been done with respect to the need for patients to undertake far more complex transport routes? Mobility challenges across both boroughs. Northwick Park is notoriously difficult to reach and there are accessibility difficulties to the St Mary’s site.
- The Transport Advisory Group has had little or no information.
- ‘Traffic has got worse, much worse – this holds up blue lighters.’
- For those who have no access to cars – many in the Acton area - there are problems with affording cab fares and complex bus routes.
- One Ealing witness reported that TfL had been approached to co-operate with travel adaptations, but nothing seems to have been forthcoming. ( see Storify)
- One patient gave first hand evidence of Patient Transport shortcomings -
3 patients plus various walking aids crushed into a minicab. On one occasion the patient reported he has passed out in the cab. Since privatisation they are often picked up late - once even arriving after the clinic had closed.
How are local GP services coping?
‘Not one health professional in a meeting could say how many could be treated in the community – it is clear that NHSEngland have no plans with regard to GP services’ Cllr Vivienne Lukey
There is a much vaunted view by those who promote closures that geographical proximity is not nearly as important as quality of care they allege can be found in super-hospitals. However whilst this is undoubtedly true of some conditions, such as stroke and trauma – several witnesses gave clear evidence that this is not true for over 80% of cases.
- Questions why the highly regarded hyper-acute stroke unit at Charing Cross needs to be re-located when others are not co-located...
- Following the publication of the ‘alarm bells’ CQC report there is ‘concern with more pressure we need more, not less, capacity’
- Worry about the local authorities’ capacity to provide the necessary home care due to severe budget cuts which have been landed on Labour – led local authorities, in contravention off equalities principles and guidelines.
- ‘Acute mental health problems won’t just go away. More patients are being treated in acute settings and waiting times are appalling.’
‘We cannot have a plan without the facts and I don’t think we have them yet’
Healthwatch Chairs came to give evidence and sadly the Ealing operation offered many a cause for concern. A board member related that he had not seen a particular document which he felt he should have had sight of. Both he and the chair then stated that the changes would impact on ‘just a small number of Ealing residents’, spectacularly failing to have kept up with the correct statistical analysis. Pregnancy not being an illness was also a rationale for reducing provision.
John Lister asked if Healthwatch is ‘there for patients or just a voicepiece for health bodies.’ A : ‘The latter – we are not allowed to campaign.’
Michael Mansfield QC asked : ‘ is it your responsibility to take a analytical view of these proposals for the sake of the local population?’
A : ‘I’ll have to think about that - I’m not sure’
Dr Stephen Hirst asked : ‘are you an information or an advisory body?’
A: ‘ what’s the difference?’
Oh dear.
The Twitter Storify from Ealing Save our NHS shows the full day’s session in more detail – including the jaw dropping Healthwatch interrogation.
The Impact of Closures So Far
So with such a complex reconfiguration, with information about only change rather than closure and very challenging new travel demands – the crucial question is: Where to go? What is the public understanding of urgent care centre v the A&E?
‘One of the things that has happened is confusion as to where to go. The sensible anticipation that other hospitals will be put under huge pressure has been borne out.’ reported an Ealing witness.
Waiting times have spiked and stayed that way. Trolley waits have hugely increased – including for the very elderly.
Relocating patients has also added valuable minutes to journey times - which is accompanied by additional pressures on London Ambulance Service who are also suffering a staff retention and recruitment crisis with a 20% paramedic shortfall.
Disturbingly, one Councillor reported that private interests are also impacting on access to paediatric provision.
Ealing A&E has reported much greater attendance and pressure on staff since C Mid and Hammersmith closures.
Northwick Park 4 hr waiting has famously dipped to a 51% - and has become the worst in the country. It also takes 1- 1.5 hrs to get there from parts of Ealing and H/F.
‘It has had a very detrimental effect on Ealing. There is a much reduced chance of getting speedy treatment - to me will be a nightmare if Ealing closes’ Ealing patient
The childrens’ A&E at Hamm having gone has had negative impacts which we entirely predictable
It is clear that medical staff in West London have felt pressurised - and it seems to be only the brave who speak out. One doctor who gave evidence has been sanctioned. Another gave evidence on past work rather than their current medical occupation. Only a small number of GPs have stepped forward.
A call to doctors and NHS from Michael Mansfield QC :
‘a whole sector of the database is excluding themselves from the debate through fear.
Can any of them come out of the woodwork? They can contribute anonymously if necessary.’
We heard from expert witness Colin Stansfield, detailed descriptions of misleading information which having been clarified through FOIs, then mysteriously changed again to show a trail of what can only be a case of figures massaging.
Consultant feedback :
‘Change should be according to need not theoretical. We are experiencing an Influx due to other hospitals not coping. On the matter of centralisation ‘It is much easier to manage home discharges close to community’
This can be backed up by the evidence supplied by Andy Slaughter where he cited the College of Emergency Medicine recently expressing the view that most people who go to A&E need A&E care – and the difference in centralising for specialisms and the clinical dangers of centralising all of emergency services. The downside is obvious: fewer centres and further to travel and distance for sickle cell, meningitis, placenta previa etc can literally mean the difference between life and death.
He was joined in this view by the doctors who gave evidence in Ealing the following week. Key parts of the magnificent testimonies by Dr Khan and Dr Sandhu are included in the Storify link.
Anne Drinkell – retired community matron and SoH secretary highlighted a key difficulty :
‘The really big problem is that CCGs are not being able to understand the messages - there are lots of reasons why they don’t want to pay attention to information and bad news.
There is a ‘big disconnect between managers and hugely overworked clinicians’.
She also provided us with a simple but relevant measure
‘ pressure sore stats are a big indicators concerning pressures on care – we are seeing a big increase’.
Michael Mansfield summarised the feedback so far, when he said ‘the fragmentation of the NHS is the overriding concern’.
There is no Plan B – and if the worst case scenario takes place then there will be no option to alter anything back ...
Save our Hospitals sum it up :
‘Shaping a Healthier Future is a cover up for cuts. We cannot see how longer journeys and fewer services are better – and with the extra pressure on staff, this is very, very, bad news.’
In all of this, the question remains Dr Spencer, Dr Spicer and Tracey Batten.
Just where will the patients go?
The next hearing will be on Saturday 28th in Hounslow Civic Centre and the final one will be in Brent on 23rd May, the other side of the General Election 2015 rubicon....
Jos Bell March 2015
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