Open Letter to Shropshire Clinical Commissioning Groups

An open letter to Dr Helen Herrity, Chair of Shropshire CCG and Dr Michael Innes, Chair of Telford and Wrekin CCG

Dear Dr Herritty and Dr Innes

We are writing this open letter on behalf of the Shropshire Defend Our NHS campaign.

On the question of two A&E departments in Shropshire, we know we disagree. We believe that there is a need for two centres to cover this large geographical area; you believe that only one is needed. That is not the focus of this letter.

The national review of urgent and emergency care makes a distinction between ‘Emergency Centres’ and ‘Major Emergency Centres’. These – like Urgent Care Centres – will not be commissioned by local CCGs, but by much more remote bodies called Strategic Urgent Care Networks¹. Each of these will cover ‘a wide geographical area’, according to initial information from NHS England. We regret that these crucial decisions on urgent and emergency care will no longer be made locally, and we believe that this sharply reduces accountability to NHS users. We are of course aware of the planned changes to urgent and emergency care nationally: that many of the patients currently seen at A&E departments will visit Urgent Care Centres instead, while the two different levels of Emergency Centres will see the most seriously ill people, those with potentially life threatening conditions².

From information given by Caron Morton to the Future Fit meeting in Welshpool on 9^th June, we understand that there will not be a Major Emergency Centre in Shropshire. Caron indicated to the meeting that the Major Emergency Centre would be at the North Staffordshire Hospital at Stoke-on-Trent. This has been confirmed elsewhere.

Does this matter? We believe it does, and we hope that there is common ground between us.

There is a sharp distinction made between Major Emergency Centres and Emergency Centres in the national proposals for emergency NHS care (the Urgent and Emergency Services Review).

The Phase 1 report states:

Emergency Centres will be capable of assessing and initiating treatment for all patients and safely transferring them when necessary. Major Emergency Centres will be much larger units, capable of not just assessing and initiating treatment for all patients but providing a range of highly specialist services. These centres will have consistent levels of senior staffing and access to the specialist equipment and expertise needed to deliver the very best outcomes for patients³.

Similarly, we are told:

Emergency Centres will be capable of assessing and initiating treatment for all patients [emphasis as original]. We anticipate that Emergency Centres in remote and rural communities, distant from more specialist services, will expect almost all patients to be directed or taken to them for initial assessment. Suitable patients will be managed by the local hospital services on the same site as the Emergency Centre. Those needing specialist treatments after assessment will be transferred; indeed critical care transfers will be a core part of the new system…

Major Emergency Centres will be larger units, capable of assessing and initiating treatment for all patients and providing a range of specialist services [emphasis as original]. Major emergency centres will have consistent levels of senior staffing and access to specialist equipment and expertise⁴.

The report also includes a diagram illustrating the difference between Major Emergency Centres and Emergency Centres⁵. The service description ‘includes specialist services such as those for heart attack, strokes, major trauma, vascular surgery, critically ill children’ is applied to Major Emergency Centres but not to Emergency Centres. Again, there is a clear distinction to be made between the two types of emergency provision. Emergency Centres and Major Emergency Centres are different.

Our acute hospitals and emergency services provide for a combined population of over 500,000 across Shropshire, Telford and Wrekin, and Powys. The strong belief of those of us in the Shropshire Defend Our NHS campaign is that a population of this size needs access to a Major Emergency Centre, offering consistent senior staffing, specialist diagnostics, and a range of specialist services. Shropshire alone covers an area of 1235 square miles, much of this rural. The most seriously ill patients already face long waits for ambulances and have to travel long distances to our existing A&E provision. (This will be exacerbated when one of our two existing A&Es is lost). An additional onward journey to North Staffordshire before specialist treatment is available is simply unacceptable. Critically ill patients need access to specialist care, but also need that care available quickly. Delays of several hours will risk lives.

We do not believe that our local CCGs are responsible for this decision. We also believe that you will do what you can to ‘make the best of a bad job’, and that you may try to maintain whatever specialist emergency services you are able to at our Shropshire Emergency Department. This, though, will not be a solution. The distinction between Emergency Centre and Major Emergency Centre is not just about designation; it is also about funding. Major Emergency Centres will be given the money by NHS England to pay for a high level of consultant cover and for specialist services, while Emergency Centres will not. If our CCGs attempt to pay for additional emergency services themselves, this means less money available for the community services that we need to keep people out of hospital. In a period where you yourselves are predicting flat NHS funding for ten to twenty years (i.e. a real terms per capita reduction in spending)⁶, the CCGs will simply not have sufficient finance to pay for extra emergency services out of its existing budget.

 There are wider issues:

• The most skilled staff – consultants and other clinicians – are likely to gravitate to Major Emergency Centres (i.e. away from Shropshire).
• It is obviously harder for family members to visit critically ill loved ones if they have to travel from Shropshire or Powys to the North Staffordshire Hospital (and it will necessarily be harder for clinicians to involve family members in decisions regarding clinical care).
• If specialist emergency services are concentrated at North Staffordshire, there is a genuine danger that specialist clinical services more generally will be at risk going forward. What is the long term future for ICU beds? What is the long-term future for vascular surgery and for stroke and cardiac services in Shropshire when the emergency care and specialist care for these conditions is relocated to North Staffordshire Hospital?

Our belief is that there is common ground between us here. We believe that NHS England has a poor understanding of the needs of rural areas. We think you share that view. We believe that a population of over 500,000 patients across Shropshire, Telford and Wrekin and Powys is large enough to justify provision of a Major Emergency Centre, with the specialist services and additional funding that go with that. We think you will agree with us. We believe that the long ambulance journey times to emergency care in this largely rural area make local provision of a Major Emergency Centre more important, not less. Again, we think you will be in agreement with us. We believe that there must be no closure of either of our existing A&E departments until new provision of equal quality is in place; a hope of new emergency provision in ten or twelve years does not justify closure of current provision. We very much hope that you will agree with us on this, and make a public commitment to this.

We would welcome your views on these issues. We also request that you join with us in making common cause to NHS England and to local politicians on a simple shared message: “We need a designated Major Emergency Centre in our area, together with the funding to pay for specialist diagnostic and clinical services”.

We look forward to your response.

Joyce Brand, Secretary of Shropshire Defend Our NHS
Gill George, Chair of Shropshire Defend Our NHS

References

1                     NHS England (30^th May 2014). NHS England News. Networks will be the cornerstone for urgent care change: Professor Jonathan Benger, National Clinical Director for Urgent Care for NHS England, updates on the Urgent and Emergency Care Review.

2                     Urgent and Emergency Care Review Team, NHS England (November 2013).High quality care for all, now and for future generations: Transforming urgent and emergency care services in England – Urgent and Emergency Care Review End of Phase 1 Report, Introduction

3                     Urgent and Emergency Care Review Team, NHS England (op. cit.), page 8

4                     Urgent and Emergency Care Review Team, NHS England (op. cit.), page 26

5                     Urgent and Emergency Care Review Team, NHS England (op. cit.), diagram page 23

6                     Future Fit Team (May 2014).“Future Fit” Clinical Design Workstream Final Report: Models of Care, 5.3.1 Financial Sustainability, page 16