Action promised on BAME access to GPs as Brent's Covid19 response comes under scrutiny

Melanie Smith, Brent Director of Public Health, told last night's Community and Wellbeing Scrutiny Committee that during the early months of the Covid19 pandemic many in Brent's BAME community felt disempowered and lacking in agency. Lessons had been learnt and Brent had realised the importance of engaging with the many different BAME communities in Brent and their community leaders. They had concentrated on Alperton and Church End which had the highest number of cases.  Messages had to be consistent and make sense to the communities concerned, for example over shielding in multi-generational households.

Confirming that access to primary healthcare was a major issue, Cllr Abdi Aden, who is of Somali background, said that many in the community who had been feeling sick had problems making appointments with their GP.  They had waited for hours in a queue at the medical centre only to give up and go home without receiving any help.

Cllr Mary Daly backed up the claim. Chair of the Committee, Cllr Ketan Sheth, interjected to say that many in the BAME community still suffered from a poor GP offer.

Dr MC Patel, chair of Brent CCG and NW London NHS lead on inequalities, offered to go with Cllr Aden to the surgery to address the issue of practices not affording access. He said unnecessary denial of access should not be tolerated.  He offered to talk to groups of 5 or so from the community to listen to their experiences and take action. 

Government guidelines recently issued should mean more face to face appointments with GPs rather than on-line arrangements which discriminated against those without internet access or lacking in English language,

Earlier in the discussion the high rate of BAME Covid deaths initially had been attributed to people not going to their GPs early enough. A speaker from Brent Healthwatch said that many residents had been hesitant about going to Northwick Park Hospital and were wary about getting infected there. Cllr Janice Long asked if late admissions to hospital was the cause of the higher death rate in Brent. She pointed out that there was only one medical centre in hard-hit Church End and asked what was being done to encourage people to go to their GP.

Cllr Ahmad Shahzad pointed out the structural issues affecting the BAME community including lack of opportunity and poor housing and said the death toll must not happen again - the Council had to safeguard the population. He said Public Health England and the BMA had been side-lined by the government.

Dr MC Patel said Brent CCG and NW London NHS were looking at devising an additional shielding list for Brent, that would include more people than the government list, and give them appropriate advice. The initial list did not include ethnicity as a factor and experience of the first wave means more needs to be done to include the BAME community, especially those with underlying conditions. Once offered it would be up to the individuals concerned to decide whether to be included in the vulnerable list.

Recently elected councillor, Gaynor Lloyd, said the elephant in the room was whether people would isolate as a consequence of being included in the list. She expressed doubt about a proposal to educate landlords about Covid19 and the risks stating, 'we all know about some landlords.'

 Dr MC Patel said that this was an opportunity for the local authority and health to work together. Joint work and shared commitment were necessary to make things happen and for 'Brent to do it differently.' He cited the response on care homes as being one example of success and said local hospitals had done well.  There was now a clear message to GPs to see patients face to face if that is what they wanted and the CCG were also looking at hot hubs for Covid patients.  It was a matter of 'making the best of what we've got.'

Simon Crawford of NW London Hospital Trust said that the emergency pathway at Northwick Park Hospital was now 85% of the pre-Covid level. Segregated pathways at A&E meant there were clear pathways for non-Covid patients. Presently there were 12 Covid patients in the hospital, a slight increase compared with 8 or so recently.  Patients' temperatures were taken when they first entered the hospital. Patients due for an operation were tested 3 days before the operation was due.  He emphasised, 'We are open for business. If you have an appointment, keep to it!'

He said that Northwick Park had been the busiest hospital in London at the peak and had been supported by other hospitals There had been positive coverage recently and they had been innovative in going with oxygen treatment rather than ventilating machines.  He said that Northwick Park had never run out of oxygen, contrary to reports.

The Trust has signed private sector contracts with Clementine Hospital and the London Clinic. Cancer referrals that had dropped by 50% were now coming back.

Cllr Neal Nerva, recently appointed to the Cabinet as lead member for Public Health, Culture and Leisure, said he was going to introduce a political dimension into the discussion.  Testing had become a matter of private competition and local government had been side-lined. Cllr Shahzad had been right about Public Health England being side-lined and there was also the failings of Test, Track and Trace.

Despite this, he said, the Council could not stand back, too many people were at risk in Brent.  He expressed confidence in the NHS and said people need to be seeking help for non-Covid conditions. The Alperton and Church End meetings showed the need for a wider Brent policy on social distancing and engaging with BAME communities.  Structural issues such as Housing, jobs, co-morbidities, learning for the Covid19 experience, would feed into the Council's new Health and Wellbeing Strategy.

All in all it was a useful discussion, although much more needs to be investigated and acted upon. The trio of councillors, Daly, Long and Lloyd, looked particularly effective as scrutineers.

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.

Fears over NHS services if hospital trusts merge

I have received this public statement on behalf of Brent, Ealing and Harrow Trades Union Councils

Your readers may be aware that a consultation is currently underway over the proposed merger of the NW London and Ealing Hospital trusts. The proposal is that this merger should be agreed by July of this year.

We are seriously concerned that this merger of the trusts, supposedly on financial grounds, will lead to a reduction in NHS services in Brent, Ealing and Harrow. Despite stressing that the consultation is about the merger of the trusts and not about the re-organisation of services, the consultation meetings have been told that this could lead to a “rationalisation” of services, particularly in the light of the government’s insistence that the NHS is required to make £20 billion of cuts.

We believe this merger would lead to a reduction of local services and people having to make often long and difficult journeys across West and North-West London. Already the consultation process seems more a P.R. exercise for a decision that has already been made.The bigger merged trust will be even less accountable and responsive to the needs of local people than the services are now.

We have already seen the closure of the Accident and Emergency Department at Central Middlesex Hospital at night, with growing expectation that this “temporary” closure will become permanent. There are fears that one of the 3 district general hospitals involved (Ealing, Central Middlesex and Northwick Park) will close. Such moves transfer services from where they are needed to where it is financially most convenient.

As secretaries of the Trades Union Councils in the 3 boroughs involved, we intend to closely monitor what is happening, and to campaign vigorously to defend our health service in all its aspects.

To this end we will shortly be convening co-ordinated meetings in all 3 boroughs to which we will invite health campaigners, NHS trades unionists and everyone who relies on the NHS to establish such a campaign.

Any readers wishing to be involved or to know more, can contact:

Brent: Ben Rickman ben.rickman@gmail.com

Ealing: Eve Turner eveturner@btopenworld.com

Harrow: John Rattray johnprattray@btinternet.com