Local Labour parties have contributed the following joint response to the Special Administrator’s report on the future of health services in South London.
The consultation ends on 13 December – so there’s still time to give your views. The full questionnaire is available from Ipsos Mori. There’s more information is available on the NHS website – including a short summary of the draft report from the Special Administrator.
Recommendation 1: Improve the efficiency of South London Healthcare Trust
- To what extent do you agree or disagree that the efficiency of the hospitals that make up South London Healthcare Trust needs to improve to match that of top performing NHS organisations?
- To what extent do you agree or disagree that the areas outlined in Chapter 5 of the consultation document for improving efficiency at the hospitals that make up South London Healthcare NHS Trust are appropriate?
- What further comments, if any do you have on any of the proposals outlined around recommendation one in the consultation document, including the reasons for your answer to questions 1 and 2? Please also suggest any improvements you would like to suggest to this recommendation
Improvement in efficiencies is welcome, but the report raises a number of issues in this area.
Inevitably the process of benchmarking raises the question of similarity between SLHT and those trusts used for comparison. The demographics of the SLHT vary considerably, and inevitably so do the healthcare needs of the local populations. Whilst this is a useful exercise, it is a questionable assumption that because operational efficiencies are achieved in one area of the country that same degree of efficiency can be transferred to South East London. Only when a detailed action plan emerges will the possibilities and shortcomings of this approach be exposed.
Whilst it is noted that clinician support has been claimed for the proposals to consolidate services on specific sites, this is no guarantee that services will not suffer, particularly given the savings intended to be achieved through reductions in staff. Reducing the number of clinicians by around 20% (140 of 862) raises considerable cause for concern, particularly at a time of rising populations, and existing services that hospital users experience as already stretched.
The lack of detail on the £12-£14m savings from the nursing budget is also concerning. It is understood that there are vacancies within SLHT currently, which have contributed to the need for temporary and agency staff, or for existing staff to do overtime. The staffing situation has apparently been exacerbated by the lack of certainty over the future of SLHT’s services, with on-going reports of shortages in areas such as midwifery at QEH, and that staff resignations have accelerated at Lewisham in recent months. It is not clear what these savings mean in the reduction of the number of posts, perhaps by not filling existing vacancies. The lack of detail on savings from nursing staff contrasts markedly with the precise number given for clinicians.
There is also a concern that the consolidation of services at specific sites will cause travel problems for patients, and their friends and families, especially those reliant on public transport, which will particularly impact upon the poor and elderly. It is known that recovery is speeded up with the support of friends and family and that their input is key to recuperation at home. One unintended consequence of more problematic travel could therefore be slower recovery times and increased hospital stays.
More work needs to be done to ensure patients have reasonable access to services and to formal and informal support. Whilst anticipated improvements in community care should mitigate this, there needs to be confidence in these systems, both in their equity and their funding.
Recommendation 2: Develop a Bexley Health Campus at Queen Mary’s Hospital Sidcup
- How far do you support or oppose the proposal for Queen Mary’s Hospital, Sidcup to be turned into a Bexley Health Campus?
- How far do you support or oppose the proposal for the land and buildings required for Bexley Health Campus at the Queen Mary’s Hospital, Sidcup site to be transferred or sold to Oxleas NHS Foundation Trust?
- What further comments, if any do you have on any of the proposals outlined around recommendation two in the consultation document, including the reasons for your answer to questions 4 and 5? Please also suggest any improvements you would like to suggest to this recommendation.
Queen Mary Hospital should retain its name and purpose as a hospital and not be reconceptualised as a ‘health campus.’ There is a broad support that the QMS site should continue to be run by a NHS provider, the Oxleas NHS Trust. However, the proposal raises a number of issues, particularly given the range of organisations that will be involved, as Oxleas Trust will manage the site, but with a number of providers working from there.
In the longer term Oxleas Trust will be in the position of landlord, rather than necessarily providing, managing, or taking overall responsibility for healthcare provision. There needs to be assurance that a full range of NHS provided services will be available in the long term, with a clear strategy for how these will be offered and maintained, and that the proposed short term arrangement for Dartford and Gravesham Trust to provide services does not lead in the long term to increased outsourcing and privatisation once this arrangement is concluded. Local people need to know that their local NHS services have a future.
There is also concern about the co-ordination, co-operation and continuity of care between these providers, how much they will work together and how much as competitors, particularly if there is greater private sector involvement which the proposed arrangements make more possible. The conditions under which this facility operates need to be robust and transparent if it is not to become a health department store with different providers vying for attention.
Under a Picture of Health QMS would have become the main centre for elective surgery for SLHT. Given the difficulties many patients from areas such as Bexley, Erith, Thamesmead, and parts of Eltham may have in getting to Lewisham this original proposal should not be removed from the available options.
Oxleas is a local trust which has established itself as reliable and cost-effective. If the fragmentation of the NHS is to continue then Oxleas is a reasonable option for managing this site. However, the NHS should be one estate, right across London, offering NHS services freely and fairly to all. This will become more difficult once strategic bodies such as NHS London are closed down.
Recommendation 3: Making the best use of buildings owned and leased by South London Healthcare Trust
- How far do you support or oppose the recommendation that South London Healthcare NHS Trust should sell or no longer rent poorly used or empty buildings?
- What further comments, if any do you have on any of the proposals outlined around recommendation three in the consultation document, including the reasons for your answer to question 7? Please also suggest any improvements you would like to suggest to this recommendation.
It needs to be recognised that such sales are one-offs and should be undertaken only if the trusts involved are confident that such facilities will not be needed in the future. Whilst this is an attractive strategy in the short term, to pay down the deficit, it needs to be done within the framework of a well thought through investment plan that identifies development priorities for years ahead and that ensures that short term expediency does not result in longer term cost. It would be unwise to sell off parts of the estate which might mean the trusts have to turn to external providers for the provision of buildings in the future – particularly given QEH and PRU experiences of PFI.
Included in such planning should be possible repurposing of buildings, for example, where patient records are stored in rented archive space these could be relocated to existing buildings within the local NHS estate.
Another consideration should be community care planning and how the intention to move healthcare closer to where people live could be facilitated by changing the use of existing buildings.
Recommendation 4: Department of Health provides additional annual funds to cover part of the costs of the PFIs
- How far do you support or oppose the recommendation that the Department of Health provides additional annual funds to cover the additional costs of the PFI buildings at Queen Elizabeth Hospital and Princess Royal University Hospital
- What further comments, if any do you have on any of the proposals outlined around recommendation four in the consultation document, including the reasons for your answer to question 9? Please also suggest any improvements you would like to suggest to this recommendation.
We are strongly in favour of this recommendation. It recognises the intolerable burden that these badly drawn up PFI contracts placed on QEH and PRU.
However, it should be recognised that the additional subsidy will still be drawn from public funds, just not from the funds of these hospitals.
Work needs to be done to change the contracts, by act of parliament if necessary, to put these PFI costs on a fairer footing, one that provides a more reasonable balance between the public purse and returns to the investors. We welcome the suggestions made by the TSA at public consultation meetings that his work has led to suggestions to the DoH that such work is undertaken to re-formulate these PFI contracts.
Recommendation 5: Transform the way services are provided across hospitals in south east London
- How far do you support or oppose the recommendation to implement the community based care strategy as outlined in Chapter 8 of the consultation document?
- What further comments, if any do you have on any of the proposals outlined around care in the community and closer to home in the consultation document, including the reasons for your answer to question 11? Please also suggest any improvements you would like to suggest to this recommendation.
A greater emphasis on community based care is to be welcomed to provide care more conveniently for patients and to promote lifestyles that lower the number of people needing hospital care overall. However, the strategy as outlined in Appendix I whilst high level is only aspirational and is seriously lacking in any detail or commitments from the parties involved.
There are a number of variable factors that bring an element of risk to this part of the overall strategy.
- The number of parties involved, including six local authorities, all the NHS trusts in the region, with Oxleas, and potentially the third and private sectors.
- It is dependent on the strategic planning of the CCGs, which may not conveniently fit with the SLHT plan.
- There is already a shortage of GPs in South East London, which contributes to the number of people inappropriately attending A and E departments.
Other factors need to be in place to ensure the success of The Community Based Care Strategy, and therefore the TSA’s plan, and ultimately the sustainability of the re-formed trusts. This includes proper funding for CCGs and successful cooperation and co-ordination between all the various actors.
Local authority provided care is already under severe pressure with worse cuts to come and the extent to which NHS funding for the purpose can meet the demand is uncertain. Further work needs to be done with regard to funding through CCGs to ensure that community care is funded fairly across the whole region, and that shortfalls in one borough are not borne by increased costs in others. Any deficit in provision in community care could result in increased NHS costs through longer hospital stays.
Furthermore care in the community has suffered disproportionately from scandals in both public and private provision. The recruitment, training, retention and management of appropriately qualified staff receiving fair pay and operating under decent conditions of service are well known problems which seem to increase rather than diminish with outsourcing and privatisation.
The community care plan plays an integral role in the TSA’s proposals, but there are many factors that need to be addressed, which brings into question the confidence placed in it as a central part of the overall strategy.
- How far do you support or oppose the proposed plans for delivering urgent and emergency care in south east London?
- What further comments, if any do you have on any of the proposals outlined around urgent and emergency care in the consultation document, including the reasons for your answer to question 13? Please also suggest any improvements you would like to suggest to this recommendation.
We are not persuaded by the TSAs arguments and do not agree with his conclusion that south east London needs fewer Emergency Care units. We are opposed to the downgrading of services at Lewisham from Emergency Care to Urgent Care. This change will mean that not only frontline A and E services are affected but also wider hospital services such as ICU and complex paediatric care. There are some questions over the accuracy of figures used to exemplify this change, including the additional travel times for ambulances, and public transport, across the region.
The change will also put an additional burden on the already stretched services at both QEH and PRU.
QEH has had to close at times, even to blue light ambulances, due to lack of resources. It also has to absorb some of the out of hours GP work, or provide such services for unregistered patients. Despite this it is pleasing to note the improvements that continue to be made in emergency care at QEH.
Whilst across the SLHT area the population is growing, this increase is greatest in Greenwich and then Lewisham. Both areas need the full range of hospital services for existing and future populations. Paragraph 77 of Appendix E of the Report notes, “that there are different views on the expected population growth and birth forecasts within south east London over the next 3 – 10 years and agreement should be reached so that correct capacity requirements can inform the final recommendation.”
The proposal creates an obvious hole in the emergency healthcare provision of south east London, with just two A and E departments for four London Boroughs. A large area of the SLHT will be without much health care provision, such as the northern parts of Bromley, exacerbated by the plans to relocate services away from the Beckenham Beacon.
- Which of the following options would you prefer, if any, for providing obstetric-led maternity services:
- Obstetric-led services should only be provided at the four major hospitals that will offer care for those who are most critically ill (King’s College Hospital, Queen Elizabeth Hospital, Princess Royal University Hospital, St. Thomas’ Hospital)
- A stand-alone obstetric-led unit should also be provided at University Hospital Lewisham, in addition to the four above
All the hospitals of the SLHT region need to provide a full range of maternity services. The stand-alone unit at Lewisham only needs to come into existence if other services, such as the ICU there, are withdrawn. Whilst there are arguments that increased specialisation in maternity services can improve outcomes (as acknowledged in A Picture of Health) as previously noted, given the age profile of the increasing populations of the area, it is likely that maternity services will be an area where there is greater demand in the future. It is not clear where any increased capacity will come from – particularly if the number of Obstetric lead services is reduced by one.
- How far do you support or oppose the proposed plans for providing planned care services in south east London?
- What further comments, if any do you have on any of the proposals outlined around planned care in the consultation document, including the reasons for your answer to question 17? Please also suggest any improvements you would like to suggest to this recommendation.
This proposal could see people required to travel further to receive care (notwithstanding the changes in community care) with a focus on specialisms at regional centres.
It also makes the provision of services vulnerable to privatisation as discrete units could be in place at any of the hospital sites that provide a specific service, raising concerns about accountability and continuity. We are opposed to any privatisation of NHS services, with the threat of a shift of accountability from patients to shareholders, and deferred lines of responsibility.
There are some questions also about the future of services provided across SLHT, for instance, no mention is made of the regional Urology services currently provided by PRU and whether these will continue to be provided there. Continuity of services needs to be assured.
Recommendation 6: Delivering service improvement through organisational change
- How far do you support or oppose the recommendation for South London Healthcare NHS Trust to be dissolved, with current NHS services managed and delivered by other organisations?
- How far do you support or oppose the plan for the Queen Elizabeth Hospital site and Lewisham Healthcare NHS Trust to come together to create a new organisation?
It is to unfortunate that A Picture of Health was derailed before the impact of its strategy could be realised. This suspension contributed to the current situation.
There is some sense in the proposed reconfigurations of south London hospitals. The demographics of Lewisham and Greenwich, for instance, are quite closely aligned.
However, there are concerns that the long-term viability of the trust may not be assured if the proposed merger of Guys, St. Thomas, and Kings goes ahead, particularly with the addition of PRU. Such a ‘super-trust’ would threaten to undermine the intent of these proposals to address the issue of patient mobility between trusts and the subsequent funding shortfall that arises.
The profile of PRU could be argued to sit more comfortably with Lewisham and Greenwich. Where it not for the on-going PFI issue a reconfigured SLHT could also have been considered with these three hospitals coming together.
- Which of the following options would you prefer, if any, for the running of the Princess Royal University Hospital?
- The PRUH should be acquired and run by King’s College Hospital NHS Foundation Trust
- A procurement process should be run allowing any provider from the NHS and/or independent sector to bid to run services on the PRUH site
Our preference is for PRU to be run by Kings, a fellow member of the local NHS family. Outsourcing, particularly to the private sector, introduces issues of accountability and whether commercial or patient concerns take priority.
However, even in this configuration there are concerns that the future of services currently available at PRU are not guaranteed. In seeking to maximise economies of scale, and to make use of existing resources, Kings College Hospital may decide to rationalise services away from PRU, particularly if the proposed ‘super trust’ merger with Guys and St. Thomas’s goes ahead.
There needs to be detailed consultation with the public if there are significant changes to the delivery of services including relocation of provision. This is particularly true given the case of the outcome of the consultation on Orpington Hospital. The uneconomic use of space at Orpington Hospital was put forward by Bromley NHS and the TSA as the main reason to close it, following a number of controversial closures of units over the past few years. The alternative arrangements suggested for the highly regarded hydro-therapy pool at Orpington Hospital seem very inferior, particularly given the heavy public investment in this facility. A Well Being Centre is proposed as an alternative for some services but with scant detail to enable judgement to be made as to whether this would be satisfactory. There is surely an argument for retaining those services in an existing establishment such as the Orpington Hospital even at the expense of some spare capacity. That might well be needed in the light of the 6% rise in population numbers referred to in the TSA draft report. The TSA draft report relies very heavily but with little practical detail on care in the community reducing pressure on the number of hospital beds but this may well be cancelled out by the rise in the elderly population, not to mention the recent Dr. Foster report on the dangerously high level of occupancy of hospital beds.
Local people need to be closely involved at all stages of any changes emerging from new arrangements, particularly given their experiences with Orpington and the Beckenham Beacon. The public need to be reassured that services at PRU will still be viable following such a merger.
- Is there anything else you want to say about the consultation or the issues it covers? If you want to explain any of your answers or you feel the questions have not given you the chance to give your views fully, or if you think there are options we have not considered that we should have done, please say so. Please also say if there are any improvements you would like to suggest to the recommendations.
Strong pleas to use discretion to extend the timescale have received a bland response that does not reply to the issues raised. The TSA has freely admitted he neither desired nor needed further time. Such views ignored the difficulties the general public experienced in responding to complex issues and masses of detail which hitherto were largely the preserve of those involved and expert in the NHS generally and the SLHT area in particular. For this consultation, and therefore the whole ‘unsustainable provider’ regime, to have validity there needs to be public confidence in it, which is not established through a rushed process.
The TSA report is intended to provide a framework for the provision of long-term, sustainable services across south east London. For all of the hospitals in this area it seems that change is the only constant. There is no guarantee that the stability this report seeks to introduce will be achieved, for a number of reasons.
The efficiency savings the TSA proposes are dependent on the hospitals performing to a level that only the top centile of hospitals in the country perform at. It is an ambitious ‘ask’ for them to achieve this in such a short space of time, particularly if services are not only to be maintained but improved. Additional funding may be needed in the short term to cover the costs of the proposed changes.
The TSA’s plan is dependent on a Community Care strategy that is still developing, involves a number of agencies and providers, and crucially is beyond his remit. Delivery on this element of the overall strategy is uncertain.
The developing ‘super-trust’ in the West of the region may act as a strong magnet which draws patients, and therefore funds, out of the newly formed trusts, thus preventing another element of the overall strategy from working.
Whilst there are problems with efficiencies and with funding within these hospitals, the overall problem is caused by the way in which the health service is structured, with establishments and providers required to act in competition with each other, and treated as though they are commercial corporations rather than public services. Were the NHS to be considered as one entity then, whilst efficiencies would still be sought, a funding shortfall would not have arisen, as across the hospitals of this region as a whole there is a surplus.
The underlying problem is that the structure of healthcare in London is such that the inner ring of teaching hospitals will constantly be perceived as more attractive for patients, and staff, than the general hospitals in the outer areas. As such funds will continue to flow in an inward direction.
As long as we persist in trying to operate the NHS on a commercial model, with health services in competition, we will continue to return to the same problems on a regular basis.
The TSA argues a persuasive case for his strategy for SLTH, but it rests upon aspirational assumptions, many of which are outside his brief. This may not be the last attempt to address these issues. Alternatives need to be considered, such as a reframing of how the NHS is conceived, a sustainable ‘Plan B’ perhaps, should these approaches fall short.
Submitted on behalf of Old Bexley and Sidcup CLP, Bexleyheath and Crayford CLP, Bromley and Chislehurst CLP, Beckenham CLP, Orpington CLP, Erith and Thamesmead CLP, Eltham CLP, Greenwich and Woolwich CLP.