On Monday, February 18, Telford and Wrekin Council will be holding an Extraordinary Meeting to discuss referring the decision to proceed with Future Fit to the Secretary of State for Health and Social Care. This is a procedure laid down in the Health and Social Care Act of 2012 when a local authority believes that a decision by the health bosses is not in the best interests of local people. It will halt progress on Future Fit until the Secretary of State has ruled on the proposals and may result in the health bosses being told to look again.
In advance of the Meeting, Shropshire, Telford and Wrekin Defend Our NHS has written to each individual Councillor to urge them to support the referral, but to do so on the basis that we need both our A&Es. The letter is below.
We are writing to you in advance of the Extraordinary Council Meeting on Monday 18th February.
Firstly, and most importantly, we share your strong concerns over the outcome of the CCG Joint Committee meeting of 29th January. The meeting itself was in many respects shoddy, as was the consultation that preceded it. The decision will leave us with a hospital that is too small to meet demand, and with increased journeys to care that will cost lives. There is no question that the outcome is detrimental to healthcare for Telford and Wrekin people (as it is for Shropshire and Powys people).Referral to the Secretary of State for Health
At this point, a referral to the Secretary of State for Health is the right move, and potentially offers a good chance of the outcome being reviewed and changed.
However, a referral has to be very robust indeed. The Secretary of State has the option of passing a case to an Independent Review panel for further review but does not do so automatically. A majority of referrals to the Secretary of State fall at this initial hurdle. From discussions at national level, we know that a referral has to be strongly evidence-based, and that a case that is based even in part on assertions is unlikely to succeed. We have also been advised that a referral that seeks to prevent risk to one population by passing that risk to a neighbouring population is itself unlikely to succeed.
As a campaign, Shropshire, Telford and Wrekin Defend Our NHS has argued over a long period that Future Fit as a whole is flawed, and that we need an alternative to Future Fit that starts from patient need. We very much hope that this will be the broad approach taken by Telford and Wrekin Council, and that this approach will have cross-party support. The alternative – a case that Option 1 is bad, but Option 2 is good – is extremely unlikely to succeed and would have to be opposed by Defend Our NHS. Our whole history as a campaign has been to advocate high quality healthcare for all of us in this area, and to reject the tactics of health leaders who have sought to set community against community.
Why Future Fit cannot meet local health needs
Spiralling demand at Princess Royal and Royal Shrewsbury Hospitals
In July last year, direct access to the Shropdoc phone number was replaced by NHS 111. Subsequently, in October last year, Shropdoc launched a reconfigured service with only a single GP available after midnight. Two or three years ago, there would have been eight GPs working this shift across Telford and Wrekin and Shropshire. We know this reduction in service is affecting patients quite profoundly, including palliative care patients needing urgent pain relief. We learned last week that the NHS 111 and Shropdoc changes are also having a very significant impact on both our hospitals.
This was discussed in detail at a hospital trust Board meeting on 7th February. Ambulance arrivals at our A&Es have increased by 17% between January 2018 and January 2019. A&E attendance has increased by over 13% over the same period. Emergency admissions have risen by a similar percentage. Ambulance arrivals are particularly high (up to 40 to 50% higher) on Sundays and Mondays, perhaps reflecting the reduced access to Shropdoc over the weekend. We were told at the meeting of the increased pressure on staff and the difficulties for patients and their families.
The Chief Executive and his Board colleagues were very clear that the increased pressure on hospital services for the most part did not reflect changes to population health. Rather, it was almost certainly related to the introduction of NHS 111 (with NHS 111 sending 11% of patients to A&E in place of Shropdoc’s 3%); and by reduced patient access to out of hours GP care from Shropdoc.
This gives us a glimpse of the future. Changes to a phone number and changes to one service – Shropdoc – have had a negative impact on the ambulance service, our A&Es, and on hospital admissions. Future Fit will increase ambulance demand as average journey length increases; will reduce the number of clinical and support staff; and will reduce the bed base at our hospitals by 110 beds. Those changes will take place at the same time as spending on community NHS services is reduced on a scale never before experienced in this area.
The plans are about increasing demand – and simultaneously reducing the capacity within our local NHS to meet demand. Our local hospital trust is already struggling, with the most recent data from NHS England showing SaTH to be the 5th worst organisation in the country at meeting the 4-hour A&E target. This genuinely cannot be about Option 1 versus Option 2. These options are marginal variations of a project that will provide worse healthcare and worse health outcomes.
There is a significant body of evidence now that longer journeys to emergency care result in worse outcomes (including increased mortality) for patients with time critical conditions.
Distance to planned care also matters. There is a phenomenon known as ‘distance decay’. Longer journey times affect attendance, health outcomes, and quality of life.
This means that either Future Fit option will harm Telford and Wrekin people, just as either option will harm Shropshire people and Powys people. Shrewsbury has not ‘won’ – for the simple reason that Future Fit is about far more than which town gets to keep its A&E.
One of our strongest concerns is that NHS funding for our area is inadequate. Our ‘STP’ area of Telford and Wrekin and Shropshire together will receive almost £25.5m LESS in 2019/20 than if we were granted the average level of per capita funding in England. The bulk of this shortfall is from Telford and Wrekin, where funding per person is £115 below the England-wide figure. We believe that this needs to be resolved – but a current priority for health leaders is to sharply reduce NHS spending in our area (by £150 to £160m a year). This is a poor basis for building a new local NHS that meets people’s needs.
The promised £312m capital funding for Future Fit comes with a cost – a drain on revenue that is likely to be around £11m a year (although we note the figures have slid around somewhat) . We are to have beautiful hospital buildings, but less money for frontline care. And Future Fit of course will result in fewer doctors and nurses, and a reduction of 110 beds in SaTH’s bed base.
The initial objective of Future Fit was to reduce dependence on hospital care through investment in community NHS services, primary care, and public health. The positive objective was a healthier population with access to high quality healthcare services closer to home. These changes were intended to lead to less reliance on hospital care. Unfortunately, the promised investment has been replaced by reduced spending. In Telford and Wrekin, the CCG had planned to spend £23.7m on community NHS services in 2018/19 – but instead, reduced this to £19.8m. Shropshire CCG intends cuts of £12.5m to community NHS services over the next five years. One strand of this is a £5m reduction in the community hospital budget, and we know this includes planned cuts to community hospital beds. SaTH leaders are concerned about any reduction in community capacity because SaTH services are already stretched to (and beyond) the limit.
Public health allocations to local authorities continue to reduce and face an uncertain future beyond 2020. Shropshire Council currently plans to end all its non-mandatory prevention services from April onward. This is to include smoking cessation, although smoking related illness is the major cause of hospital admissions in Shropshire. It is a given that hospital admissions will increase as a direct result.
Service cuts in Shropshire will inevitably put hospital services under increased pressure. You will know that hospital services are struggling to cope, despite the heroic efforts of staff. It is therefore inevitable that Telford and Wrekin people will themselves be detrimentally affected by cuts to community and public health services in Shropshire. It is also worth noting the instruction from NHS England that our own area – as with other NHS areas – will move to having a single system-wide financial target this year, with increasing financial integration. This means there is no ‘opt out’ for Telford and Wrekin.
New and better community services and improved population health are essential building blocks of the Future Fit project. Without these, Future Fit proposals simply cannot work. We know from GPs of escalating concern about Future Fit. GPs already work under immense pressure. Primary care cannot absorb the additional workload that will result from reduced hospital services, reduced community services, and decreased spending on public health. Health leaders are in the process of creating a perfect storm.
The Chair of Telford’s Business Board has spoken out today against Future Fit, commenting ‘Telford and Shropshire has a rapidly increasing total population together with massive increase in housing numbers. One A&E will not be fit for purpose in the future let alone today’. Absolutely correct.
We know of senior staff at hospital trust SaTH who believe that Future Fit is clinically unsafe. An established climate of bullying leaves them unable to speak out publicly.
The reality is that closing either A&E will put intolerable pressure on the one that remains. A second – and very significant – concern is that operating a Planned Care Centre on the stripped-down basis that is planned will put patients at risk.
Our view is that the absolute priority is to unite and stop Future Fit. If Future Fit is implemented, local residents will be harmed – irrespective of which town retains the A&E. Our strong belief in Defend Our NHS is that an area three-and-a-half times the size of Greater London needs both A&Es. We are not opposed to NHS change – but local change should be in line with recognised good practice around collaboration, networking and integration; it must be adequately funded; and above all, it must start from patient need. Local people, of course, must have real involvement in shaping the outcome. If this is about healthcare for the next 20 to 30 years, we need to get it right.
We hope to see a referral to the Secretary of State, with cross-party backing, that takes this agenda forward. We would be very proud to throw our weight behind this approach.
Do please contact us if you would like any further information, further detail on the evidence behind the arguments here, or a meeting with a Defend Our NHS representative either individually or for your political group on the Council.
Gill George, Chair
Julia Evans, Secretary
Shropshire, Telford and Wrekin Defend Our NHS