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.
