Open letter to clinicians and other senior NHS staff

On 31st March, the hospital trust, SaTH, is due to sign off the Future Fit ‘Strategic Outline Case’. This is effectively the blueprint for the closure of an A&E, and the downgrading of one of our District General Hospitals to become a ‘Diagnostic and Treatment Centre’ – a planned care centre of 20 beds. A second strand of Future Fit is the transfer of healthcare from acute hospitals to community NHS settings, with a 30% transfer of activity quoted many times by Future Fit leaders.

What was Future Fit?

Future Fit, though, was never intended to be just about closing an A&E and acute hospital, and cutting back on hospital care. This was always a much more ambitious project. A core system principle within Future Fit was that ‘home is normal’, that care should be provided closer to home, and that patients should be provided with the level of care they require to avoid unnecessary acute hospital admissions[1]. There has been no pretence (until now) that this will somehow happen of its own accord. The Clinical Models report emphasised ‘the absolute requirement to create community capacity to manage the shift in care closer to home’[2]. A little later, we are told ‘Community capacity must be built to accommodate this shift… there is an absolute need to shift resources into community care’[3].

There is no room for doubt here. Future Fit focuses on care in acute hospitals and community hospitals – but in order to work, it had to be supported by improved community services, and those services would require additional resources. That was always the vision. Future Fit was meant to be about whole system transformational change[4], delivering care closer to home for a majority of patients, as well as better care for people with frailty and/or long term conditions.

There is now no money for community services

As recently as August 2015, a firm commitment was made around extra funding for these new community services. The Board of Shropshire CCG discussed and agreed new investment of £5.3 million annually, on a recurrent basis[5]. Dr Caron Morton, Accountable Officer of the CCG at the time, wrote to every GP in Shropshire, making the same commitment. The money was to fund new services to fill the gaps created by changes to acute hospital care: closing an A&E and acute hospital, and cutting hospital services by 30%. This was an identified fund solely for new community services and Urgent Care Centres. It was quite separate to the £4 million previously spent by Shropshire CCG on Integrated Community Services (ICS) and continuing care.

That money has now disappeared. In a shocking admission, Shropshire CCG acknowledged this month, ‘It is not likely that the CCG will have additional resource to invest in community services from its resource limit’. The letter from Dr Helen Herritty (then CCG Chair, now Lay Member for Patient and Public Engagement) can be found here. This is genuinely extraordinary. Without this money, there can be no new community services, and there can be no rural Urgent Care Centres in Shropshire. The Future Fit vision is destroyed. This was a project of two halves: sharply reducing care in acute hospital settings, but creating alternative provision in the community through additional investment. Without the funding for community provision, Future Fit is reduced to cuts in hospital provision – and nothing more than that. The brand name continues, but the vision has entirely vanished. Although Dr Herritty’s letter states that Shropshire CCG will seek resources from the Sustainability and Transformation Fund, this fund is intended for high performing vanguard trusts, for bailing out acute trusts that are in deficit, and for national projects such as the national cancer initiative[6]. The chances of Shropshire CCG receiving a significant recurrent year-on-year allocation from this are vanishingly small. Telford and Wrekin’s portion of Future Fit of course cannot opt out of a financial crisis affecting Future Fit as a whole (and Telford and Wrekin CCG is itself making spending cuts).

There are to be no Rural Urgent Care Centres

The concept of Urgent Care Centres (UCCs) has been central to Future Fit. The original plan was for ‘some’ UCCs, strategically placed across Shropshire and Telford and Wrekin[7].  The phrase ‘a network of Urgent Care Centres’ has been used routinely in Future Fit engagement events. The model offered to the public last summer was for seven UCCs: one at the current Princess Royal Hospital site, one at the Royal Shrewsbury site, and five Rural UCCs (one each in Oswestry, Whitchurch, Bridgnorth, Bishop’s Castle and Ludlow). There have been ambitious plans for UCCs to treat up to 80% of patients who would now be seen in the A&E departments[8]. The vision has been that all UCCs will offer assessment, treatment and monitoring facilities for adults and children, specialist care to elderly people, and provide ultrasound and X-ray facilities, 16 hours a day, seven days a week. The message to the public has been a consistent and unambiguous one. There is little public support for closing an A&E – but people have been told time and again that an overwhelming majority will be able to access high quality urgent care closer to home, at our local UCCs.

Suddenly – now that the £5.3 million has disappeared – the message has changed[9]. Suddenly, there is talk of an ill thought out ‘urgent care offer’ as an alternative to Rural UCCs. Even the ‘offer’ – which seems to consist mostly of asking GPs to take on responsibility for Point of Care testing – is subject to financial constraints. The new message is clear: there are to be no Rural UCCs. This is not a minor change. It is a stark U-turn, and it has caused deep anger at the public and GP workshops taking place this month. All of the modelling around A&E capacity has assumed the existence of Rural UCCs; every single Future Fit public engagement event has attempted to ‘sell’ the project on the basis that this network of Rural UCCs will exist. Whatever is being implemented now, it is not Future Fit.

Closing an A&E and acute hospital: Is this the right thing to do?

Our local NHS leaders say that ‘centralising’ A&E and hospital facilities will solve staffing problems and provide patients with the very best equipment and facilities, and with world class healthcare. There’s no actual evidence for these assertions.

We urge you to read the recent statement on A&E reconfiguration issued by the Royal College of Emergency Medicine (RCEM). This is the national expert body, representing Emergency Consultants and maintaining standards of emergency care across the UK. The RCEM argues that recruitment and retention difficulties are ‘poor justification for service reconfiguration’. They note the consequences for patients, for services at sites required to absorb diverted patient flows, and warn of the additional stress on primary care.

The RCEM notes that ‘increased travel times are associated with worse outcomes for some patient groups with time critical illness’, comments on the increased demands on ambulance services brought about by longer transport time, and highlights the likelihood of transportation difficulties in rural areas. Ambulance response times are a crucial issue in Shropshire. A report to Shropshire Council’s Health and Adult Social Care Scrutiny Committee this month confirmed that the ambulance service is in crisis, with a recent period where no ambulances were available within the county to respond to emergency calls. Shropshire CCG’s Director of Strategy and Service Redesign acknowledged at the meeting that ambulance response times are ‘unacceptable’. With a single Emergency Centre, average ambulance journey times will increase – leaving even fewer ambulances to respond to calls. There is of course no allocation of funds within Future Fit to invest in the ambulance service.

The RCEM also notes the disproportionate effect of relocating services on the very young, the very old, patients with mental health issues, and those with chronic illness or reduced mobility. The RCEM view is that ‘moving resource/capacity issues does not solve them’ and cites the evidence that the cost efficiencies associated with reconfiguring clinical services are ‘largely illusory’.

Local NHS leaders have misused RCEM guidance on recommended staffing levels in an attempt to justify local A&E closure. The RCEM statement (and the discussions we have had with a senior representative of the RCEM) make it quite clear that using staff shortages to justify A&E closure is inappropriate. The RCEM urges a comprehensive risk assessment of ten key areas wherever reconfiguration of services is planned. SaTH believes that no risk assessment is necessary. Our local NHS leaders find themselves sharply at odds with the national clinical experts.

Could closing one of the A&Es and acute hospitals actually solve staffing problems locally? It seems extraordinarily unlikely. The approach has not worked at the centralised Women’s and Children’s services at the Princess Royal Hospital. There are deep-seated workforce planning, training and contractual issues in today’s NHS, which will not be resolved by merging the two A&Es and acute hospitals. Concentrating services on one site would make the organisation of medical rotas a little easier – but there is a trade-off between frequency and intensity. Fewer but busier ‘on-calls’ by no means guarantees recruitment. There are things that SaTH could and should do, however. Removing the threat of imminent A&E and hospital closure could help to recruit or retain Consultants, and addressing the long-standing ‘permafrost’ between senior managers and frontline staff remains crucial.

We have also looked at research on the consequences of A&E closure, and at accepted best practice for the provision of healthcare in rural areas.

A&E closure costs lives. A UK study shows that longer ambulance journeys lead to significantly higher overall mortality rates[10]. A US study shows that there is a ‘knock on effect’ of closing A&Es: that mortality rises sharply even at remaining A&E departments in the vicinity of one that has closed[11]. Last year, an Imperial College review of increased death rates in Newark, Nottinghamshire, found that up to 50 people a year die needlessly following closure of the local A&E[12]. Dr Clare Gerada, former President of the Royal College of GPs, commented, ‘Common sense would say that if people are having to travel further, this will increase mortality for a range of acute conditions’. Of course some patients will have better outcomes if they travel further but receive more specialist care. This is not an argument for making around a half of SaTH’s patients travel further, in the full knowledge that some of them will die as a direct result. ‘Time critical care’ is called that for a reason – it is time critical.

The challenges facing rural areas have not been dealt with properly in the Future Fit model. The area served by SaTH is around 90% rural, and more than 60% of the population lives in an area designated by the ONS as rural. Rurality cannot be an afterthought. The RCEM has advised strongly against closing A&Es serving rural areas, advising that any benefits of centralisation are lost because of the long distances travelled to access care[13].

For all healthcare – from emergency care through to primary care – access is the key consideration in rural areas. Interestingly, this reflects the patient feedback given throughout Future Fit public engagement events. Models that prioritise centralisation and specialisation to the exclusion of access may (sometimes) be appropriate in urban areas, but are inappropriate in areas like our own. Poor access to healthcare means that people seek care later or not at all, with worse health outcomes as a result. The evidence base around rural healthcare is summarised well in a recent review commissioned by the Welsh Assembly[14].

Is there a robust evidence base for Future Fit?

The West Midlands Clinical Senate – the clinical experts in our region – reviewed Future Fit, reporting in January 2015. It seems that our local clinical leaders are out of step with the regional experts as well as the national ones. The reviewers highlighted clinical and financial risk, were unconvinced of workforce assumptions, expressed doubt on whether proposed reductions in activity were achievable, and noted the existence of ‘several modelling assumptions which either assert novel causal relationships or else are significantly in excess of previously achieved outcomes’. This would roughly translate into ‘We think they’ve got this wrong’. The regional experts urged the development of a ‘backup plan’ – a Plan B.

The modelling behind Future Fit plans is important. Modelling will determine the number of beds there will be in the single acute hospital, and the capacity of the remaining A&E unit. Currently, there are insufficient bed numbers at our two acute hospitals. The CQC noted last year that local bed occupancy was at a level that could damage patient care[15], and our hospitals on a semi-routine basis declare high escalation levels (with the Princess Royal Hospital at the highest Level 4 only last week). A shortage of acute beds creates ‘exit block’ for our A&Es. Patients cannot be admitted to the hospital from A&E – which in turn leaves A&Es without the capacity to accept patients coming into A&E. This then leads to ambulances stacking up outside A&E, unavailable to respond to other calls. The Future Fit modelling we have seen shows a planned reduction in the number of acute beds[16], at a time when our ageing population will increase demand on healthcare services.

If Future Fit assumptions are wrong, there is a strong risk that the hospital will have too few beds, and the A&E will be overwhelmed by demand and reduced to chaos. We believe that the assumptions in Future Fit are over-optimistic. Future Fit Modelling, for example, predicts a 32% reduction in emergency admissions of people with frailty or long term conditions by 2018/19[17]. The figure is significantly in excess of NHS England estimates, themselves unproven – and NHS England modelling assumes spending increases of 22% on primary care and 24% on community care[18]. We have not met a single local clinician who believes that this Future Fit estimate is credible – but this and similar assumptions are determining future bed numbers.

Local NHS leaders are similarly optimistic about the numbers of patients to be seen in Urgent Care Centres, arguing that 80% of patients who would currently be seen in A&E will be treated in UCCs instead. The evidence-based recommendation from the RCEM is that it is safe for 15 to 20% of A&E patients to be seen in GP-led UCCs[19]. Are we to believe local NHS managers with a clinical background, or the national clinical experts?

The modelling, carried out by the Commissioning Support Unit, cites an evidence base that is – putting it politely – suspect. Estimates of future disease prevalence, for example, use sources that include a 1998 BBC news report, and draw very heavily on the Brighton and Hove Council 2014 Annual Public Health Report[20]. It is no wonder that the West Midlands Clinical Senate remained unconvinced.

Even if the modelling were correct at the time, it is likely to be invalidated by current plans from Shropshire CCG; for example, to cut bed numbers in community hospitals, to reduce the availability of patient transport for planned care, and to force patients needing out of hours care to go through NHS 111 rather than Shropdoc. All of these moves are likely to increase the pressure on local acute services. We know that hasty revisions are being applied to modelling now, in a desperate attempt to shore up Future Fit. The removal of all funding for community services, however, means that quick fixes to a bankrupt project cannot possibly produce a coherent and workable model for our local NHS.

In an attempt to alleviate patient concerns, leaders of Future Fit are making public statements that are at best seriously misleading. A recent Future Fit blog, co-authored by the Medical Director at SaTH, suggests patients should not worry about longer ambulance conveyance times because paramedics will administer ‘clot busting drugs’. Paramedics do no such thing. It would be potentially life threatening for stroke patients prior to a head scan, and sub-optimal for those with a serious cardiac condition. If misleading the public is the only way Future Fit can gain support, we are in a very dangerous situation.

A recent comment on Future Fit from one local clinician was, ‘This is a car crash in slow motion’. It is worth reflecting on this before this project simply rolls on.

What now?

The impression has been given repeatedly that all clinicians support Future Fit plans. We know this is not true, because we have spoken to countless clinicians (in acute and community settings) who are desperately concerned. We also know clinicians who support a shift to community-based care in principle – but who know that this cannot work in the absence of funding. The disappearance of funding for out of hospital care is a particular issue for GPs and other clinicians in primary or community healthcare roles. It is GPs, more than anyone else, who will be expected to simply absorb the extra workload. The clinicians in the West Midlands Clinical Senate urged the development of a backup plan. We believe there’s an urgent need for this to happen. It is time to call a halt to Future Fit, and to look at ‘bottom up’ change in a careful, collaborative – and funded – way instead.

There’s something else that needs to be done. Future Fit is now about balancing the books, a cost saving exercise at the expense of patients. There isn’t enough money coming into our local NHS now, and there is no scope at all for the NHS cuts planned over the next five years.

This is purely and simply about the safety of local people. Governments can always find more money when they need to; we’ve seen that most recently over budget plans. NHS leaders and senior clinicians in Shropshire and Telford and Wrekin are very aware that there is just not enough money in the system. A clear and united statement that patient safety is being put at risk by insufficient finance would influence local politicians, and would put real pressure on the Government to review local funding allocations. We believe it’s time for patients and NHS staff to unite together in calling for adequate funding and an NHS that works for all of us.

Gill George MSc
Chair, Shropshire Defend Our NHS

Julia Evans BSc (Hons) RGN ENP
Secretary, Shropshire Defend Our NHS

[1] Future Fit Clinical Design Workstream. Final Report. Models of Care 5.1 page 15. May 2014.

[2] Future Fit Clinical Design Workstream Executive Summary page 7. Op. cit.

[3] Future Fit Clinical Design Workstream 5.1 page 16. Op. cit.

[4] Future Fit Clinical Design Workstream 9. page 61-62. Op. cit.

[5] Shropshire CCG. Minutes of 12th August 2015 Governing Body meeting.  page 19/402. Accessed 27/03/16.

[6] HSJ. Only the strongest vanguards will get extra funding. 14th March 2016.

[7] Future Fit Clinical Design Workstream 6.1.4 page 29. Op. cit.

[8] Verbal response to public question, Chief Executive Simon Wright, at SaTH Board meeting, 28th January 2016.

[9] Presentation and slides at Rural Urgent Care Workshops, March 2016.

[10] Nicholl J, West J, Goodacre S, Turner J. The relationship between distance to hospital and patient mortality in emergencies: an observational study. Emerg Med J. 2007 Sep;24(9):665-8. 2007.

[11] Liu, C; Srebotnjak, T; Hsia. R Y.  California Emergency Department Closures Are Associated With Increased Inpatient Mortality At Nearby Hospitals. Health Affairs 33,8, 1323-1329. 2014.

[12] Tyrer, Professor P. For Mail on Sunday. Accessed 27/03/16.

[13] Royal College of Emergency Medicine. Written evidence to the Health Select Committee. May 2013.

[14] Longley, M; Llewellyn, M; Beddow, T; Evans, R. Mid Wales Healthcare Study: Report for Welsh Government 3.4. Welsh Institute for Health and Social Care. September 2014.

[15] CQC. Shrewsbury and Telford Hospital Trust Quality Report page 6 2015. Accessed 27/03/16. January 2015.

[16] Midlands and Lancashire CSU Strategy Unit. Modelling the Activity Implications of the Future Fit Clinical Model page 38. December 2014.

[17]  Midlands and Lancashire CSU Strategy Unit page 28. Op. cit.

[18] NHS England. Any town health system. Rural CCG data. January 2014.

[19] Royal College of Emergency Medicine. STEP Campaign page 3. 2015.

[20] Midlands and Lancashire CSU Strategy Unit. Page 60. Op. cit.

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