Open Letter to Councillors and voluntary organisations

Now: unacceptable ambulance response times, ambulances stacked up outside A&E and patients waiting on trolleys inside, not enough A&E capacity, not enough acute hospital beds, and cuts in the coming year in social care and community NHS services (including a possible loss of even more community hospital beds).

The future: closure of one of our two A&Es, one of our acute hospitals replaced by a Diagnostic and Treatment Centre of 20 beds, around 30% of acute hospitals services shifted to community settings – and NO money at all to invest in new community services or Rural Urgent Care Centres because of inadequate funding for our local NHS.

Is this what we want?

 

On 31st March, the hospital trust, SaTH, is due to sign off the Future Fit ‘Strategic Outline Case’. This is effectively the blueprint for major changes to hospital care, including a single ‘Emergency Centre’ (a combination of an A&E and hospital) instead of the two A&Es and two acute hospitals that we have now.

There’s a problem

There were always two sides to Future Fit. Closing down a huge swathe of A&E and hospital care was one side of Future Fit. Investing in new community services and new Rural Urgent Care Centres was the other side. The Future Fit vision was always about creating community-based alternatives to the hospital care that was being lost. The plan was for transformational, whole system change, providing care closer to home as an alternative to hospital care.

The money for new community services has gone

In Shropshire, the commitment last August was to invest £5.3 million every year, on a recurrent basis, into these new replacement services. This was a firm pledge – a promise made by the CCG Board, recorded in Board minutes, and contained in a letter sent to every single GP.

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, the planned community alternatives to hospital care cannot be created. The Future Fit vision is destroyed.

Shropshire CCG will seek funding from something called the ‘Sustainability and Transformation Fund’ – but this has been set up for high performing vanguard trusts, to bail out acute trusts spiralling into deficit, and for national projects such as the national cancer initiative. 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 (especially at a time when Telford and Wrekin CCG is itself making spending cuts).

The money for Rural Urgent Care Centres has gone

That £5.3 million was intended to cover Rural Urgent Care Centres (UCCs) as well. There were ambitious plans for a network of UCCs: not just Urban UCCs in Telford and Shrewsbury, but Rural UCCs in Oswestry, Whitchurch, Bridgnorth, Bishop’s Castle and Ludlow as well. The UCCs were intended to treat around 80% of patients who would go to A&E just now, and to 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.

Now, we’re headed for only two UCCs – the Urban UCCs in Telford and Shrewsbury. One of them will be instead of an A&E; one of them will act as a gatekeeper to the single remaining A&E. The plans for Rural UCCs have in the last few weeks been replaced by a poorly thought through ‘urgent care offer’ – which seems to consist mainly of expecting GPs to take on extra work without additional resources. The loss of UCCs in rural areas has caused huge anger at the Rural Urgent Care workshops attended by the public and GPs this month.

Whatever else it is, it’s not Future Fit

The Future Fit ‘brand name’ remains, but any positive elements of the project have now gone. Only half of Future Fit is left. It’s the half that’s about cutting the A&E, closing an acute hospital, and cutting hospital-based care. Without investment in new community services and UCCs, Future Fit is in tatters. Closing hospital services without putting anything in their place will cause chaos twice over: with over-stretched hospitals that cannot cope, and in our communities where the care that patients need is just not there. (That chaos will be there whichever town keeps the A&E and acute hospital. US research shows a sharp in mortality at hospitals that retain their A&E after a neighbouring A&E has closed. Cuts and closures have an inevitable ‘knock on’ effect).

Local plans: Out of step with national guidance from the experts

We urge you to look at this powerful statement on A&E reconfiguration from the national experts on emergency care, the Royal College of Emergency Medicine (RCEM). The RCEM says that staffing problems don’t justify closing A&Es, talks about the pressure that is put upon other services when A&Es close, and the problems that are created for the most vulnerable people – the very young, the very old, patients with mental health issues, and those with chronic illness or reduced mobility. Importantly, the RCEM highlights the impact on ambulance services. Locally, this is a key issue. The RCEM also argues that anticipated cost efficiencies from reconfiguring clinical services are ‘largely illusory’. The RCEM statement is a damning critique of the clumsy assumptions that have been embraced by NHS leaders in Telford and Wrekin and Shropshire.

The RCEM urges a comprehensive risk assessment of ten key areas wherever reconfiguration of services is planned. Senior managers at SaTH, the hospital trust, say that no risk assessment is necessary. In many respects, our local NHS leaders find themselves sharply at odds with the national clinical experts.

Distance matters

The RCEM quite rightly notes that ‘increased travel times are associated with worse outcomes for some patient groups with time critical illness’. Remember that these people are the national clinical experts. They firmly believe that longer journeys to A&E are dangerous for some patients, and the RCEM opposes A&E closure in rural areas for precisely this reason. The research backs up the RCEM view, showing that longer journeys lead to unnecessary deaths. One example: in Newark, Nottinghamshire, A&E closure has been followed by an additional 50 deaths a year. The risks are real and serious.

Our two hospitals, the Princess Royal and the Royal Shrewsbury, serve an area of over 2000 square miles and a population of more than 550,000 people. Closure of either hospital will result in longer ambulance journeys – and therefore an increase in unnecessary deaths – for a significant number of local residents. Patients with ‘time critical’ conditions need care urgently, and any delay at all can make the difference between life and death. It’s disappointing that the planned A&E closure has sometimes been portrayed as a ‘Telford versus Shrewsbury’ split. Most local people understand very well that we need decent healthcare for all of us, and that this means keeping both the A&Es and hospitals we have now.

The closure of the Princess Royal A&E and acute hospital would come at an unacceptable cost to people in the main population centre of Telford. Increased ambulance journey times would result in increased mortality; this is what the research and the national experts tell us. There would be a particularly detrimental impact on people living in the rural areas north of Telford. The mirror image of this is equally unacceptable. The closure of the Royal Shrewsbury A&E and hospital would sharply reduce access to emergency and acute healthcare in our second biggest population centre, Shrewsbury. Closure of the Royal Shrewsbury Hospital’s A&E would also create very long ambulance journeys for many people in Powys and in the more rural areas of Shropshire. We have seen ambulance data from a 12 month period remodelled on the basis of one or other of the A&Es being closed. Longer journeys mean higher mortality – and some of these journey times are very long indeed.

For South Shropshire, currently around 4% of residents with a time critical condition face an ambulance journey of 60 minutes or more to reach A&E. With a Telford Emergency Centre, this would increase to 14% (around 120 people in a year). In the Oswestry area, ambulance journey times would increase by an average of 19.2 minutes. This would give an average journey duration of just over 45 minutes. With current emergency provision, only 14 time critical patients (in Oswestry and North Shropshire districts combined) face an ambulance conveyance time of 60 minutes or more. With a single Emergency Centre at Telford, the number of time critical patients having to endure these very long journeys would increase from 14 to 53.

Currently, around 6% of Powys residents with a time critical condition face an ambulance journey of an hour or more to reach A&E. If these patients have to travel instead to Telford, more than half of them – an estimated 458 people a year – face a journey time of more than an hour in the back of an ambulance.

Ambulance response times must be added to the journey time to reach A&E – and ambulance response times will get worse when one of the A&Es is closed down. Loss of either A&E will mean an increase in the average distance travelled by ambulances to attend to patients and, where necessary, to take them to hospital. This will take longer. There will therefore be fewer ambulances available to respond to emergency calls. The Future Fit plans do not allocate additional funding to relieve the extra pressure that will be placed on ambulance services.

It is worth noting that local ambulance services are already in crisis, with national targets routinely missed, emergency ambulance response times of around an hour becoming commonplace in our rural areas and market towns, and a recent episode where there were no ambulances available to respond to emergency calls anywhere in Shropshire. Shropshire Council’s Health and Adult Social Care Scrutiny Committee, at its meeting earlier this month, heard the CCG’s Director of Strategy and Service Redesign describe ambulance response times as ‘unacceptable’.  Unacceptable is about to become worse.

Rurality

Future Fit has tried to apply an urban model of centralisation in a largely rural area. Closing an A&E has a good deal less impact if the next one is a five minute drive away! 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 Royal College of Emergency Medicine 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.

For all healthcare – from emergency care through to primary care – access is the key consideration in rural areas. Poor access to healthcare means that people seek care later or not at all, with worse health outcomes as a result. Future Fit leaders have simply ignored best practice and available evidence around the needs of rural areas.

Staffing

Could closing one of the A&Es and acute hospitals solve staffing problems locally? The claim that it will has been a central justification of Future Fit. It seems extraordinarily unlikely, though. The approach has not worked at the centralised Women’s and Children’s services at the Princess Royal Hospital. The West Midlands Clinical Senate questioned the workforce assumptions in Future Fit. The RCEM, as national experts, do not believe this is the way to resolve recruitment and retention difficulties. 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.

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, queried 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 shoddy. The modelling, carried out by Midlands and Lancashire Commissioning Support Unit (CSU), 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. It is no wonder that the West Midlands Clinical Senate remained unconvinced.

The modelling matters, because it will be used to determine bed numbers and A&E capacity at the single Emergency Centre. For example, Future Fit estimates are that there will be a 32% fall in emergency admissions for frailty and long term conditions by 2018/19 – despite the increasing demand from our ageing population. No clinicians believe this for one second, and the claim is out of step with NHS England modelling – but this is what the CSU number crunchers claim. There are other astonishingly optimistic assumptions about preventive programmes leading to reductions in acute illness – but there is no longer any Future Fit funding for prevention initiatives, and public health funding has already been sharply cut. The plans we have seen, based on dodgy evidence, are for fewer acute beds than we have now. This will result in a single hospital that cannot meet patient need.

The assumptions made around UCCs are equally questionable. Future Fit leaders claim that UCCs will see 80% of the patients who would currently attend A&E. They probably still say this even now they’ve taken away five of the seven UCCs we were promised! The national experts at the RCEM say that 15 to 20% of patients can be treated safely in an UCC setting. There is no evidence base at all for the assumed 80% – and if it is wrong, lives will be put at risk. The staff at UCCs don’t have the skills to assess to treat very ill patients – and the A&E will be far too small if local NHS leaders persist in the illusion that it is there for only 20% of patients.

Current plans from Shropshire CCG are likely to increase the pressure on the acute hospitals still further. Moves 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 will all make things worse. 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 reassure patients, 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. We have spoken to countless clinicians, in acute and community settings, who oppose current plans. The disappearance of funding for alternatives to 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 A&E and hospital closure, and to look at ‘bottom up’ change in a careful, collaborative – and funded – way instead.

The NHS nationally faces the worst financial crisis in its existence because funding has lagged far behind costs. This is why the overwhelming majority of hospitals in England are now in deficit. The financial crisis has hit Shropshire particularly hard, because NHS England allocations policy does not recognise the increased costs of providing healthcare in rural areas, and also badly underfunds areas with an older population. Our CCGs in Shropshire and in Telford and Wrekin are cutting NHS services in the coming financial year – not because they want to, but because they haven’t got enough money. Future Fit is now about balancing the books, a cost saving exercise at the expense of patients.

It’s a situation that is challenging for representatives at all levels: for MPs and our local authority councillors in Shropshire and Telford and Wrekin, in particular, and arguably for town and parish councillors as well. If Future Fit rolls out, an entirely predictable outcome is that existing problems in the NHS will sharply worsen, and some of the people you represent will die unnecessarily. Is keeping quiet an acceptable response? To fight only for your own corner, as one of our councils has done, is more readily understood – but ironically leads to the same result, because it offers no alternative to the chaos that is mounting in the local NHS.

This is purely and simply about the safety of local people. It is close to unthinkable that Future Fit should be implemented in its current form. There’s a wider issue as well. Without adequate funding, our local NHS is in deep, deep trouble. Please consider adding your support and your organisation’s support to the call for adequate funding for our NHS. A united approach from NHS leaders and senior clinicians, from MPs and local politicians and representatives at all levels, and from local people would give us the powerful voice we need to influence NHS England and the Government.

This is the 21st century, and we live in one of the richest nations in the world. It is simply not acceptable for critically ill people to wait an hour for an ambulance to respond to a 999 emergency, another hour to reach the A&E, and a third hour to get through the door of the A&E when they arrive. It is not acceptable either for critically ill patients in Shropshire and Telford and Wrekin to wait for many hours in the corridors of our hospitals before an A&E cubicle is free, and hours more before they can be admitted to a hospital bed. These things are happening now, in our local NHS, in March 2016. We need adequate funding and positive change, not the year-on-year cuts that are now planned.

Gill George MSc
Chair, Shropshire Defend Our NHS

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

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