I am writing to update you on the outcome of the meeting at the racecourse yesterday on the future of Epsom Hospital. Unfortunately, but not surprisingly, the representatives of local GPs agreed to move to the next stage of the process. They agreed to the principle of the plans and to move ahead with a meeting of the different GP groups involved in this process in two weeks time, which will almost certainly confirm that there will be a public consultation on downgrading Epsom Hospital.
What was most disappointing was that the GP representatives made part of the case for change on the basis of factually incorrect evidence, despite being challenged on the accuracy of what was being said. I have written to them following the meeting to raise concerns about what took place, and also to seek answers to key questions which remain unaddressed.
The one bright spot is that Dr Claire Fuller, who chairs the GP group, has in her reply to my recent open letter left open the possibility of retaining more than a midwife led maternity unit at Epsom. However we are still a long way away from securing agreement to that.
I have included below a copy of the response that she sent me, as well as a copy of the one I have just sent.
The Epsom Hospital Campaign steering group will meet this week to discuss the next steps in this battle. I am then planning to hold a meeting for those who are willing to become local organisers in the campaign on Tuesday 28th May, at 7.30pm.
Please can you let me know in advance if you are willing to offer practical help to the campaign and so want to attend the meeting, as this is not meant to be a big public meeting. I will be sorting out the venue this week based on how many people are coming. After that I will send out a further email bulletin giving you details of planned campaign activities.
Thank you to everyone who came on Friday for the support they gave. There were around 700 people present, which should at the very least be an indicator of how strongly people feel about this.
With best wishes
Thank you for your previous correspondence on Better Services Better Value and you’re your continued interest in the programme. I have separated the concerns you have raised into broad themes and will respond to each issue in turn.
Possibility of developing a local solution for Epsom Hospital
I was also pleased with the level of interest at Surrey County Council meeting in developing viable solutions for our local health economy, and would welcome further discussions about how local services should be configured. I believe that there is a vision for Epsom Hospital emerging as a campus site containing services from a number of providers. Subject to consultation, this could see the retention of an expanded world class elective centre, perhaps augmented with surgery provided by specialist London trusts. There could be community in-patient beds, with a full suite of rehabilitation and reablement services provided by both the NHS and social care to ensure that people are cared for close to their family and friends and swiftly supported to return home. The site would retain full outpatient services but again specialist providers would be invited to provide services from the site to increase access. Rather than provide full emergency and full maternity services, Epsom would concentrate on continuing to provide the bulk of services to the local population, with specialist care moving to the major acute hospitals (as it already does in a number of clinical areas). We would wish to agree a model for urgent care on the site that ensured that the majority of people could continue to safely access services at Epsom. We also want a model that provides convenient on-site access to paediatric services and community paediatric support outside the grounds of the campus. Subject to demand and viability, we would also wish to have a model that continued to allow low-risk births to take place on the site.
Will BSBV proposals improve the quality of care for residents?
The proposals have been developed by senior clinicians from Surrey Downs and South West London and are based on best practice nationally as defined by the Royal Colleges. Not all of the clinical working groups had 100% unanimity, which is to be expected, and in some instances it was clinicians from Epsom and St Helier who were in the dissenting minority. We believe that centralising services has produced significant benefit in London in the treatment of stroke and major trauma and believe there is an opportunity to get similar improvements from centralising emergency care, higher risk maternity and in-patient paediatric services. With regard to maternity services, you rightly point out that that neonatal and perinatal mortality rates at Epsom are significantly lower than other BSBV trusts. The case mix at Epsom is significantly skewed towards “low risk” partially because of the demographics of the surrounding area, but also because complex cases during the antenatal period and pre-term babies are already transferred to St Georges in recognition of the requirement for more specialist care. Therefore the mortality rates do not indicate higher quality but the lower risk births seen at Epsom. For moderate or high risk pregnancies there needs to be a solution in place that has a high level of consultant cover and access to more specialist services, but lower risk pregnancies services could be offered at Epsom, either via a stand-alone midwife led unit or other service.
The proposals will require significant capital investment as you rightly point out, but keeping services in their current configuration are also likely to incur capital costs, given some of the issues with infrastructure at hospitals like St Helier. As you are aware there is no guarantee of availability of capital, particularly before any strategic case is agreed, and this does present a risk. The Business Case does reflect the expected cost of capital in line with Treasury guidance. We have considered in detail the possibility of expanding Epsom to become a major acute hospital that meets the London clinical standards, but in the scenarios modelled the hospital has a recurrent deficit of £4.5 – £6.5m which would render it both financially unsustainable and unattractive to potential providers both public and private. In our view, regardless of BSBV, there would need to be significant changes in the services offered at the Epsom site. As local commissioners we would be joining any consultation process prepared to consider a range of alternative scenarios that could be capable of delivering the improved quality that we seek. It is true that Epsom and St Helier’s financial position has improved but they are not anticipated to reach break-even this financial year. Their Board are considering whether they have viable plans to get to Foundation Trust status which may require reconfiguration of services across the two sites irrespective of BSBV. The NHS Trust Development Authority has not publicly changed its view that Epsom and St Helier is not capable of achieving Foundation Trust status in its current organisational form, and I am aware that the Transaction process with Ashford and St Peter’s was halted because a break-even position was not attainable with the restraint on reconfiguring services at the Epsom site. The movement of activity from one provider to another as envisaged in BSBV is intended to increase quality, it would not per se, save any money for a CCG, however it would reduce operating costs for the overall health system and under the preferred options, ensure Epsom’s long-term financial viability. It would also provide the opportunity to maximise the site for other services, either for specialist providers to allow local access to high quality services or for community led services to ensure the need for acute care is minimised.
Conflict of Interest
I understand that you have received concerns from constituents regarding GP’s referring patients to private organisations that they control. These arrangements clearly have the ability to potentially inhibit patient choice and restrict the competition that they were designed to encourage. The CCG is working with its local clinicians, to ensure that none of our providers or practices are (intentionally or not) breaching guidelines. In discussion with our localities and practices we are considering whether to centralise referral and patient choice processes to remove any suggestion of conflicts of interest. I would be keen that you raise any concerns that you come across directly with me to ensure that they are addressed.
Impact on Surrey providers
The changes proposed in the Business Case have an impact on other Surrey providers, principally St Peter’s, East Surrey and the Royal Surrey hospitals. The travel impacts have assumed that if services move from Epsom, patients will chose their next nearest hospital. More patients may choose to travel to Kingston, St George’s or Croydon because of the enhanced standards, or more may prefer Surrey as you suggest, so our assumptions appear to reflect a medium position. The CCG’s in Surrey are committed to driving up standards at all Surrey hospitals over the same timeframe as the potential BSBV timeframe, although given that there has been far less preparatory work to date in Surrey, it is unlikely that they will be able to meet the same standards as London. The impacts are unlikely to create a large capital requirement for Surrey hospitals. Most hospitals are planning to reduce beds over the next few years as lengths of stay in hospitals continue to reduce and more community services support people, without the need for admission. If there is a greater flow of admissions into these hospitals then less beds will be redundant, meaning these could be maintained without capital cost.
Out of Hospital services
In your letter you raise a number of concerns related to the need for increased provision of services within primary rather than secondary care. The CCG has already developed services that are working in partnership with all providers to reduce or shorten acute hospital admissions, such as virtual wards, the Community Assessment Unit and community hospitals. This work will need to continue at an increased pace, and the BSBV proposals are predicated on further investment in primary care and community care to ensure that we have the necessary capacity to enable people to access the services they need. Surrey Downs CCG is currently developing a comprehensive Out of Hospital Strategy, led by clinicians within our four localities, to support this work.
We believe that the preferred option offers a great opportunity to not only preserve a nationally recognised elective orthopaedic centre, but to increase its scope to include the majority of elective surgery in Surrey and South West London. If this option is agreed following consultation and elective surgery therefore decommissioned at the major acute sites, the activity will either flow to the elective centre or commissioners will not pay for the activity. Other NHS providers are also interested in providing services at an elective centre at Epsom, recognising the economies of scale of having a critical mass of elective theatre capacity.
Movement of clinicians to London hospitals
As you note there will be a movement of senior clinicians to London trusts in order to drive up the quality and safety at the major acute sites. There will be a requirement that services are delivered in a networked fashion to ensure the continuity of high quality local services. Whilst in-patient paediatrics beds are proposed to be concentrated on major acute sites, we will retain paediatricians supporting out-patient services and community facilities such as those supporting disabled children on the Epsom site. The models are based on not changing the point of delivery of care for most people. Currently there is a big difference between what can be treated at St George’s and what can be treated at Epsom. The public already accept that if they have major trauma or require emergency surgery they will not be seen at Epsom, but the majority of people who currently attend Epsom A&E will continue to, under the new model. Only the sickest will need to attend the major acute hospitals where they will be met with the best standards of care 24 hours a day, seven days a week. I fully understand the concerns you have raised on behalf of your constituents and it is important that these are considered by us as local clinicians and by the Better Services Better Value programme to ensure any proposals are fully developed and will deliver improved clinical outcomes for our patients.
We understand local people are worried about any proposed changes at Epsom, however as an organisation we are committed to delivering better care for our local population. We believe there is an opportunity to drive up standards of care for our patients and it would be wrong for us to ignore this. As you are aware, safety and staffing issues mean we cannot continue to safely provide every service on every site and that means difficult decisions will need to be made. We will not shy away from these and we will continue to ensure patients, and their clinical needs are at the heart of any decisions we make, both in relation to Better Services Better Value and the healthcare we commission for local people. As you will be aware, each of the seven CCGs involved in the review are currently considering the proposals that have been developed at their Governing body meetings. If every CCG agrees, the proposals would then be subject to a three month public consultation. We will of course continue to involve you as the programme progresses.
Dr Claire Fuller Clinical Chair
Cc Surrey Downs CCG Governing Board members, Surrey Downs GP practices
Thank you for your letter setting out your response to the issues I raised with you last week. I will make your answers available to my constituents.
However I am afraid that I am also writing to express my enormous disappointment at the way in which the CCG handled Friday’s meeting, and at the way in which inaccuracies in the presentation to the Governing Body were left unaddressed.
I had hoped and expected that there would be a serious discussion of the issues around the table, in order to give the public confidence that at least their local GPs are aware of the concerns and are debating them properly. Instead what we had was little more than a rehash of what has already been presented by the Better Services Better Value team, and serious issues raised from the floor were mostly left unaddressed. I am writing to you therefore to seek from your Governing Body clear answers to those questions that have been raised with you, and which remain unanswered.
Most particularly, why was factually incorrect information presented to the meeting as part of the justification for change? On two occasions during the presentation, material arguments presented to the Governing Body as part of the justification for change were based on inaccuracies. The first was the claim that the move to a 24/7 consultant presence on maternity wards was now a Royal College requirement. As you will know, when the RCOG published the current guidelines, it acknowledged that the 24/7 aspiration was unlikely to be achievable in the near future because of cost pressures. At present Epsom hospital is fully compliant with RCOG guidelines, and no changes are due which could alter this. When you were challenged on this, no formal attempt was made to correct the record.
The second issue is that the meeting was told that other Surrey Trusts are all working towards the same 24/7 objectives. Letters from the Royal Surrey County Hospital and from Surrey and Sussex Healthcare Trust to Surrey County Council in the last few days make it clear that this is not the case. Your letter to me confirms that they will not be able to meet the same standard as London. Again no formal attempt was made to correct the record.
I was to be frank astonished that representatives of the local General Practitioners could feel it appropriate to act in this way. I wait your confirmation about how you will deal with this.
In addition, I believe that you now need to take legal advice before taking any further action in relation to the BSBV programme. I am not a lawyer, but I believe that in using inaccurate information in this way at a decision making forum, and failing to correct the record when challenged, the CCG has opened itself to a serious risk of Judicial Review. I believe that you would be in danger of acting outside your fiduciary responsibilities if you were to proceed without taking further clear legal advice. I was disappointed that you did not agree to do so on Friday afternoon.
In addition, I would be grateful if you could explain why it appears that members of the Governing Body were not provided with prior notification about the nature of the decision they were being asked to take. When Cliff Bush raised concerns about this, you then registered his vote as an abstention without offering a chance for a negative vote. Why was this?
Separate from the issues of legal propriety, I know that the 700 or so people who came to the meeting will have gone away with a real sense of frustration that they saw no evidence of a more serious discussion between members of the Governing Body. In a nutshell, the impression left was one of a simple stitch up, without even a clear indication, as I had hoped, that serious consideration would be given to other options in the months ahead.
There are a number of basic questions that remain unaddressed, and to which I would now publicly invite you to give answers.
- What guarantee can you provide that patients from the London CCG areas will use Epsom as an elective centre? If patients in those areas choose to exercise patient choice, and the three Foundation Trusts choose to offer elective services, what is to prevent all of the work remaining in London?
- Who will control and have responsibility for the administration of Epsom Hospital following if St Helier Hospital loses all of its inpatient services, and the Epsom and St Helier Trust becomes unviable as a result? This question appears to have been ignored by all involved.
- BSBV’s pre-consultation documentation claims that the hospitals being covered by the review are not meeting Royal College guidelines for patient safety. Please will you confirm which Royal College guidelines Epsom Hospital is not currently meeting? In particular will you please confirm that Epsom’s maternity unit currently meets those guidelines.
- Please can you explain how paediatric services will operate in the Surrey Downs area in future if consultant-led care is not available at Epsom Hospital. Epsom is unusual in that hospital and community paediatrics are integrated. This was clearly a concern even among your governing body. Please can you explain what the successor arrangements will be?
- Epsom currently has a 24/7 A&E department, but does not offer emergency surgery. Please will you confirm that the new Urgent Treatment Centre will only be open twelve hours a day? Please can you confirm whether or not local GPs will operate an out of hours service for the remaining twelve hours, and where that service will operate from? You will be aware that concerns have been raised over the years about the existing arrangements. Please can you tell me how these will be changed, and who will provide the service? Will the CCG and its members take back delivery of this service?
- Please can you indicate whether or not South Coast Ambulance Trust has agreed that it will routinely transfer patients into hospitals in London, and what the extra resource requirements will be? Who will meet the cost of the additional ambulance capacity?
- It was clear from the meeting that even your Governing Body has serious doubts about the issue of travel times. Are you in a position to give a clear categorical assurance on behalf of the Governing Body that you are satisfied that no patient safety issues will arise as a result of increased travel times? Please can you publish the information you have been provided by the ambulance trust about the worst case estimates of travel times to the nearest acute centres.
- You have estimated that an additional £51m will need to be spent at other Surrey hospitals to support the changes resulting from BSBV. In addition, I assume that the Surrey health economy will have to bear some of the cost of supporting the £2-300m capital spend required within the BSBV area. You will also be aware that additional out of area funding is likely to be required in London. This is likely to lead to a bill of well above £300m of capital, as well as the annual cost of depreciating that capital. Can you give a categorical assurance as you seek to enter a consultation process that will inevitably destabilise services in the coming months that you have been given a clear undertaking by NHS England that capital funds will be available to pay for all of this?
- Why is the secondary care representative on your board a consultant from one of the London hospitals that stand to gain from these changes, and not one who is locally based? Can you provide an assurance that he has played no part publicly or privately in the discussions about these proposals.
I do not believe that you need accept change on this scale. You have a projected balanced budget for the coming year. The deficit of the Epsom and St Helier Trust has fallen rapidly and the Trust is off the Department of Health’s list of top concerns. There are clearly substantial savings to be made in Surrey by integrating primary and secondary care facilities and treatment. Epsom is currently a safe centre by national standards.
I believe that the local medical community is less and less convinced of the argument for change, and it is a matter of great disappointment to me (and I know of surprise to many of them) that unlike in Sutton, they were not asked to vote on the proposals.
At the very least, I had hoped on Friday that there would be a clear statement from your Governing Body that you would begin a Surrey based review alongside the BSBV consultation, and that you would publicly state that you would not automatically accept the end findings of the BSBV process. This would have played a major role in alleviating local concerns, and I thought that this is what you were planning to do. The fact that you were not able to do so means, inevitably and disappointingly, that you and your participating practices will face a summer of intense public pressure.