Butt poses key questions on future of NHS provision in Brent for Executive endorsement

The Brent Executive will be asked to retrospectively endorse a personal submission made by Council Leader Muhammed Butt to the Independent Reconfiguration Panel. The IRP was gathering evidence on the Shaping a Healthier Future plans for health services in North West London which include the closure of Central Middlesex A &E  and submissions closed  yesterday.

Th IRP will report to the Secretary of State on September 13th and his decision will be made in October 2013.

Muhammed Butt's Submission

I am writing to you to express my views on the Shaping a Healthier Future programme (SAHF). It is accepted that the NHS needs to change and services have to evolve but I have some serious concerns with the proposals as they stand, and whether they can really deliver improvements to health care in North West London within the planned timetable for implementation. I support the referral that Ealing Council has made to the Secretary of State for Health that will see the Shaping a Healthier Future proposals reviewed by the Independent Reconfiguration Panel. It is important that the plans are subject to robust and independent scrutiny and that the modelling and assumptions built into the proposals are properly tested.

Out of Hospital Care

SAHF makes it clear that changes to out of hospital care are essential if it is to deliver the planned changes to acute care. The general princip le of transferring services from acute to community locations with investment in primary and community care, where appropriate, is welcomed. People should not have to travel to hospitals for routine care or to manage a long term condition.

That said, I am concerned about whether the proposed changes can really be delivered, and even if they are, will they deliver the reduction in demand for acute services that SAHF claims?

I have seen no guarantees that out of hospital care will get the investment in the near future that is needed to ensure that SAHF can deliver improvements. The business case outlines the level of out of hospital care investment required, but in times of financial pressure and constantly shifting priorities, I need cast iron assurances from all of the CCGs in North West London that this money will be allocated to out of hospital services that underpin SAHF no matter what other challenges are faced in the coming years. 
 

The Decision Making Business Case (DMBC) is clear that commissioners and providers should not undertake reconfiguration of hospital services until out of hospital care is shown to be working and have sufficiently reduced demand on acute services. But I need clarity on exactly what the thresholds are for the reduction in demand that will need to be met before the reconfiguration of acute services is allowed to begin, particularly on critical services such as A&E.

I also need to be convinced that delivering more and more services out of hospital will be cheaper for the NHS. There is an assumption that this is the case, but I have seen no evidence to support it. One of the benefits of providing services in a hospital setting is the critical mass that can be achieved by locating services in one place. For some services, such as maternity, we will see a reduction in the number of places services can be offered.

For other services, we will see an increase in settings as services are delivered away from hospitals. The CCGs need to demonstrate more clearly how out of hospital services will be cheaper.

While there appears to be a general consensus of support across CCGs in North West London for the provision of out of hospital care, the provision of this falls to individual CCGs and individual Out of Hospital Care Strategies. A failure to deliver an Out of Hospital Care Strategy in any one CCG areas could have a knock oneffect on neighbouring CCGs, particularly if it affects demand on shared acute care services. For example (and this is hypothetical), if Harrow CCG fails to reduce demand for acute services, how will this affect Brent residents using Northwick Park Hospital where services could be under extreme pressure? Similarly, in these times of stark finances and shifting priorities, if one CCG decided to reduce its commitment to out of hospital care, it is not clear what the effect would be on neighbouring boroughs and shared acute service provision.

GP Support and “Hubs”

The Out of Hospital Strategy underpinning SAHF cannot succeed without GP support and I note that one of the key issues listed in the panel’s terms of reference is the consideration of GP’s views. I have seen no evidence of grass-rootsGP support for the changes, particularly in relation to out of hospital care (I refer to GPs themselves rather than the CCG). Although GP events took place, the DMBC gives limited reference to them, despite the report’s acknowledgement that Health Scrutiny Committees in North West London had made it clear that they expected to see evidence of GP support.

It seems to be a general assumption throughout the decision making process that the support of CCGs should be taken as implicit supportof GPs. This is an erroneous and dangerous assumption. Shaping a Healthier Future relies heavily on additional out of hospital services and without the full buy-in and cooperation of GPs SAHF will face serious, if not insurmountable, challenges. I ask that the IRP challenge the CCGs to provide the full details and results of the GP engagement activities that were undertaken to demonstrate that there is GP support for their proposals

Besides the lack of evidence of general support fro m GPs, we have seen little evidence that GPs will be prepared to make changes to the way they work or provide additional services/support that is required. SAHF and the CCGs needs to satisfy the panel that the GP elements of the Out of Hours services can be delivered, and what the back-up alternatives are in cases where it proves they cannot.

One of the key elements of the Out of Hospital Strategy is the provision of additional local medical centres (“hubs”). Yet purpose built centres that already exist in Brent have not fulfilled their potential. Monks Park Medical Centre for example remains under-occupied and consequently underused. Similarly, I understand that the NHS Brent has failed in the past to encourage a GP practice (the Willesden Medical Centre) to relocate into the Willesden Centre for Health and Care (one of the designated hubs) despite considerable efforts. I urge the panel to fully investigate SAHF's claims that the proposed centres will really be able to deliver on their promises across NW London and particularly in Brent.

Evidence from Brent to date suggests that efforts to move GP practices into purpose build medical centres have not succeeded and that they remain committed to working from their existing premises. Why should SAHF change this?

Given that “hub” medical centres are a central component of the Out of Hospital strategy underpinning SAHF, I need to see more clarity on exactly what services are planned for each hub. In particular there needs to be clarity on exactly what services will be provided at Willesden Centre for Health and Care and for Wembley Centre for Health and Care, which are already large medical centres in Brent and two of the designated hubs. I also want to see assurances that no existing services at these sites are going to be removed.

GP access is already a serious issue in Brent, particularly in the south of the borough, and previous attempts by the PCT to address this have had little success. Since SAHF is dependent on increasing GP access I urge the panel to establish with the CCGs (particularly Brent CCG) what evidence they have that that their new attempts to increase GP access will succeed where previous attempts have failed. Without this A&E attendances and acute demand will continue to rise.

Changes to acute care

I have seen little tangible evidence to support the models for individual services leading to reduction in demand on acute services. I acknowledge that there will be an element of risk in the modelling of any service reconfiguration, but the scale of change is huge and the impact of the Out of Hospital services not producing the required reduction in acute demand could be catastrophic. To this end I urge the IRP to establish what mitigation plans there are if the model fails, either for individual parts of the reconfiguration or for more fundamental modelling of the reconfiguration as a whole.

An example of a proposed service change that causes me concern is the provision of maternity beds at Northwick Park. Under the proposals there will be an increase from 69 to 70 beds by 2015/16, but a 20% increase in births atthe site. This appears to be based on the questionable assumption that a 15% reduction in average length of stay can be achieved by 2015/16. I ask the panel to establish what provision has been made if North West London Hospitals fails to deliver the numbers proposed?

Previous attempts to reduce acute demand through faster discharge have been unsuccessful and I would be interested to hear why SAHF believes it will succeed where previous attempts have failed.

I am particularly concerned about the deliverability of the proposals - maternity is one example. Changes on the scale proposed by Shaping a Healthier Future would ideally be carried out in a stable and highly functioning health system. But, we know that the NHS is in crisis, and North West London is not immune to this

.

Central Middlesex Hospital

It will come as no surprise to you that I am concerned about the future plans for Central Middlesex Hospital. Central Middlesex serves the south of Brent, which contains areas of significant deprivation and poverty. Has there been any research done on the evening closure of A&E at Central Middlesex that is already in place, and its effect on Northwick Park, St Mary's and other neighbouring hospitals? Northwick Park’s A&E Department is already failing to perform adequately or safely. Unless out of hospital services deliver a marked reduction in the use of Northwick Park’s A&E, the removal of A&E services at Central Middlesex could cause Northwick Park hospital to reach breaking point.

I note that North West London Hospitals and Brent CCG both support the plans for the closure of A&E at Central Middlesex but that does not alter the fact that there is a genuine, strongly felt public opposition to this plan which cannot be ignored and I urge the panel to give this strong consideration when they consider the proposals.

It is proposed that Central Middlesex be an elective hospital with an Urgent Care Centre. However, there is a complete lack of information on precisely what elective services will be delivered at the site, and what catchment area they will serve. It is also unclear what the UCC will provide despite plans for a standard UCC offer to be developed across London. A working group set up to develop plans for UCCs has,to the best of my knowledge, not published any proposals. I need to see clarification from Brent CCG on its plans for services at Central Middlesex Hospital and assurances on its long term viability as an NHS hospital before I can support the proposed changes.

Northwick Park Hospital

Northwick Park has struggled for some time to deliver an adequate or safe A&E and has one of, if not the worst, “four hour waiting time” performance in the country. It has recently had a crisis summit focussing on A&E leading to the imposition of an “Implementation Plan” to address the issues. Is it really prudent to give extra A&E responsibilities to a hospital that has shown itself incapable of delivering adequate A&E services to date and what is being put in place to manage these increased risks? The recent risk summit at the Trust highlighted the depth of the problems that currently exist and I have serious concerns about how you can transform a system which is already in crisis.

In addition, the response to the current A&E crisis at Northwick Park has been to utilise facilities at Central Middlesex. What back-up options will there be in the future once Central Middlesex’s emergency facilities have been removed?

Equalities and Population

Many residents of the south of Brent suffer deprivation and hardship. It is an area with a high proportion of BME residents and residents with English as a second language. We have sought assurances from SAHF that these communities will not be unduly disadvantaged by the reconfigurations and particularly the closure of Central Middlesex A&E.

In particular we have sought clarity on the travel implications for both patients and residents. To date we remain dissatisfied that sufficient consideration has been given to this. Clinical priorities are cited as being more important, but we should not ignore the fact that the mental health and recovery of patients can be dependent on regular visits and support from family and friends and I urge the panel to push for clarity on the effect that the changes would have on low cost transport options for patients and visitors, particularly in this deprived area. We would similarly seek assurances from Brent CCG that it will take seriously the public transport implications to the medical centre "hubs", which besides being an equalities issue, could reduce the numbers of patients using these services.

Conclusion

I want Brent Council to work constructively to challenge our NHS colleagues. I am not opposed to change without good reason, but I remain concerned at the lack of clarity in key areas, including: 

 

• The ability to deliver better out of hospital services

• That Northwick Park Hospital will be able to provide additional acute services for an expanded population

• The future of Central Middlesex Hospital. Despite the Shaping a Healthier Future plans being published a year ago, I am no closer to understanding what will be delivered from the Central Middlesex Hospital once it becomes an elective centre.