We are writing to you about our concerns over the reorganisation plans for local hospital care.
On Tuesday, the joint CCG Board meeting has as its main agenda item the ‘Future Fit Strategic Outline Case (SOC)’. There is an immediate problem here. This is not a Future Fit Strategic Outline Case.
A 27th April email from Simon Wright, Chief Executive of SaTH, to Shropshire Defend Our NHS confirms this. Mr Wright makes a clear distinction between SaTH’s Sustainable Services Programme and Future Fit, stating ‘The Board recognises that communication around the two aligned but separate programmes of sustainable Services and Future Fit has been confusing for the public and we are hoping to make this much clearer going forward’. Mr Wright clarifies the remit of the SOC, explaining ‘The SaTH Board is concerned with ensuring we have two healthy and vibrant hospitals’, and adding ‘On this basis the Board has approved the Sustainable Services Strategic Outline Case and the CCG will be asked to do the same’.
It could not be clearer. Mr Wright regards Sustainable Services and Future Fit as separate programmes. He believes the SOC is part of the Sustainable Services Programme, not part of Future Fit. This is Hospital Fit not Future Fit. This is not a whole system approach.
Will Community Fit can somehow haul things back, and identify the resources for new community and primary care models that will plug the gaps left by reductions in hospital care? No. The sole aim of Community Fit in the Terms of Reference approved by the two CCGs is: ‘… to deliver a sustainable, community based, health and social care system focussed on prevention and continuity of care, delivered by integrated teams of clinicians, through bespoke local solutions utilising their unique local asset base’. The focus is on using the resources and staff that are already there, the pre-existing ‘unique local asset base’, and not transferring resources.
The SOC is not about transformation of the healthcare system across Shropshire, Telford and Wrekin. This is about SaTH seeking to resolve its own financial and organisational issues in isolation, and seeking CCG support for this. If this approach continues, the implications for GPs, community NHS services and patients are profound and damaging.
Activity Assumptions
In January 2015, the West Midlands Clinical Senate published a ‘critical friend’ review of Future Fit. The Clinical Senate report did not believe there was an adequate evidence base for many aspects of Future Fit, and called for the development of a back-up proposal. Some comments from the Clinical Senate report:
‘The stage 1 review was necessarily limited by the early phase of the FFP, and a range of untested, underpinning hypotheses’.
‘The panel was of the view that there are several modelling assumptions which either assert novel causal relationships or else are significantly in excess of previously achieved outcomes’.
‘The panel were of the view that the proposed reductions in activity through preventative strategies within FFP are ambitious, as reductions of this magnitude have not previously been achieved within the NHS, and it was yet to be evidenced whether this will result in a reduction in clinical need, activity and bed occupancy’.
Those untested underpinning hypotheses have not been revisited by the programme. If they are wrong, then all subsequent activity modelling is also wrong – and the proposed capacity of the single Emergency Centre will fall far short of what is actually required.
The Activity and Capacity subgroup[i] that agreed the assumptions assumed that emergency admissions associated with either frailty or long term conditions would fall by 32% by 2018/19 due to better primary care management, better use of community hospitals, and reductions in the prevalence of key risk factors (smoking, cholesterol, alcohol consumption, blood pressure etc.).
More generally, the subgroup assumed 20% reduction in falls related admissions, 15% in vaccine related admissions, and up to 20% reduction in alcohol and smoking related admissions over a 5 year period.
The group – 17 members, fewer than half of them clinicians, and including only two GPs (Dr Gowans and Dr Hudson) – was not encouraged to identify an evidence base for its assumptions. Core assumptions were derived from ‘contextual information and knowledge of planned or potential QIPP schemes’. The assumptions made by this group have been dismissed by Shropshire’s LMC as ‘optimistic in the extreme’. They are not credible, particularly in an era of ever-tightening finance in the NHS and large-scale cuts to public health programmes and social care.
Subsequent estimates for the number of patients to be seen in Urgent Care Centres (UCCs) also at odds with reality. Recent research[ii] shows that around 25% of patients ‘streamed’ to a UCC subsequently require transfer to an A&E/Emergency Department. This alone would result in a required an increase in capacity of the single planned Emergency Department of 56% (and a significant increase in ambulance journeys to move patients from the standalone UCC to the Emergency Centre). The Future Fit assumption that 69% of ‘front door’ urgent care patients can be managed in UCCs is at odds with NHS England’s estimate[iii] of 40%, and even more sharply at odds with the Royal College of Emergency Medicine’s study showing that a maximum of 22% of patients can be managed safely in a co-located UCC setting. A 65% activity transfer was predicted when a UCC was set up at the Royal Shrewsbury Hospital in December 2014 – but has fallen far, far short of this in reality.
The Future Fit assumptions are sharply at odds with the existing evidence base and national guidance. This is a fundamental weakness, and not one that can be resolved by a little bit of remodelling or sensitivity checking. Wrong assumptions will have led to sharply incorrect modelling of required capacity, and sharply incorrect financial modelling. If reductions or transfers of activity are ultimately in line with the national picture rather than local predictions, we will end up with an Emergency Department that is half the size that is required.
The revised letter of acceptance calls for further testing of affordability. This is built on sand unless the flawed assumptions behind Future Fit are revised, and all subsequent modelling of patient activity is revised.
Sustainability of the clinical model
The revised letter of support queries the sustainability of the proposed ‘hot and warm’ site configuration, suggesting ‘Whilst this solution appears to improve the workforce sustainability issues in our emergency and critical care unit, it is unclear whether it will provide a viable long term model of acute medicine’. Of course, there is no actual evidence that a move to a single A&E and a single critical care unit will support recruitment and retention. The Clinical Senate pointed this out, and a representative of the Royal College of Emergency Medicine told us this was unlikely to solve staffing problems.
The new hot/warm approach is in sharp contrast to last year’s model of a single Emergency Centre and a 20 bed Diagnostic and Treatment Centre for most elective care. Seven months ago, single site working was supposedly a panacea for all recruitment, retention and staff development difficulties, as well as being essential for patient care. The re-written SOC repeats many of the claims, in a crude cut and paste approach – but also calls for ‘a much more evenly balanced distribution of services’.
It is very likely, sadly, that the ‘two vibrant hospitals’ approach is not a serious one, and has been incorporated for political reasons. The planning for the hot and warm site model appears to be at an early stage. For example, the Conclusion to the SOC suggests ‘Clinically-led discussion and debate will need to continue on the best location for other essential hospital services: Women and Children’s, Surgery, Cancer etc.’ On paper, this leaves open the possibility that patients requiring major surgery or women with an obstetric emergency could be treated at the ‘warm’ site, without immediate access to critical care. Clinically, this is an improbable outcome. A recent Royal College of Emergency Medicine statement on A&E reconfiguration notes the risks of unintended or self-fulfilling consequences following A&E closure: ‘There is an inherent unintended consequence of rendering other services at the same site non-viable; by limiting the case-mix and case-load, reconfiguration exacerbates recruitment and retention issues in non-EM services such that a self-fulfilling, non-viability scenario is created’[iv] It may be no coincidence that at SaTH’s 28th April Board meeting, the Medical Director referred in passing to ‘the single site’.
Our belief is that patient needs dictate a requirement for two District General Hospitals, and two functioning A&Es. We do not believe that the quick fix solution of hot and warm sites is viable. We also do not believe that it is intended to be viable.
Where next?
The revised draft letter of acceptance going to the CCG Boards does not deal effectively with the extent of Future Fit’s failings. It is unacceptable that every area of concern is ‘kicked into touch’, to be addressed during the development of the Outline Business Case. On how non-hospital based services will cope with the extra workload, the draft is even worse. For Community Fit, the suggestion is that ‘this work will take longer than the timescale of the development of the OBC’. The requirement is therefore for ‘sufficient further work to design the model of community care and to test assumptions about … activity shifts and … productivity improvements’. The pressure to sign off flawed and incomplete proposals will be even greater in six months’ time than it is now. The area of greatest concern to local GPs is being kicked into touch twice over, with an uncertain timescale for resolution.
In January 2015, the West Midlands Clinical Senate called for the development of a back-up proposal. It did so believing that Future Fit was not evidence based, and that an alternative might prove to be necessary. This is not a choice between Future Fit and ‘doing nothing’. It is a choice between continuing with a flawed project that cannot be made to work – or moving heaven and earth to develop an alternative that can win the support of clinicians and the public. It is not too late to change direction, but every month that goes by makes this harder. We are heading for a disastrous outcome by default, because no one is brave enough to call a halt.
There are alternatives. We would like to see a ‘bottom up’ approach to change, driven by frontline clinicians. The Royal College of Physicians advocates building collaborative networks of care, based on patient need, crossing organisational and geographical boundaries. We have to build on our strong GP service, on our network of community hospitals, and on the hard work of our immensely talented and committed local NHS workers (in the acute and community sectors). Starting with what we have and making incremental changes is a far less dangerous approach than the ‘big bang’ of closing an A&E, downgrading an acute hospital, reducing the services offered in acute settings – and hoping that primary care and community NHS services will fill the gaps. We also note that a majority of smaller acute trusts in England are seeking collaborative or networking solutions to solve problems with staffing, finance and service delivery[v]. SaTH is living in the past.
The choice on Tuesday is a straightforward one. One option is to continue with a project that is regarded by Shropshire’s LMC as ‘naïve to the point of being dangerous’, and that has been described by GPs in the last few days as ‘codswallop’ and ‘a completely unworkable fantasy’. The other option is to acknowledge previous mistakes, to call a halt to Future Fit before it is too late, and to finally prioritise work on the back-up plan that was recommended 16 months ago. We urge Board members to reject a ‘letter of support’ that ducks every important issue.
Regards
Gill George MSc
Julia Evans BSc (Hons) RGN ENP
on behalf of Shropshire, Telford & Wrekin Defend Our NHS
[i] Activity and Capacity subgroup – Appendix 2c of SOC
[ii] Cowling, T et al, 2016. Referral outcomes of attendances at general practitioner led urgent care centres in London, England. Emerg Med J 33: 200-207
[iii] NHS England, 2013. The Keogh report
[iv] RCEM, 2016. Statement on the reconfiguration of emergency care
[v] Monitor, 2014. Facing the Future: smaller acute providers
Shropshire, Telford & Wrekin Defend Our NHS 
thank you once more for your commitment, clarity and directness.