Since I contacted you last week it has become clear that the Better Services Better Value team reviewing the future of local hospital services is planning to publish its recommendations sooner than I had expected. They are due out on Friday 3rd May.
I have very real misgivings about what they are set to propose, and I have set these out in an open letter to Dr Claire Fuller, who chairs the new local Commissioning Group of GPs who are taking the decisions locally. I have attached this letter below so you can see more about what is really happening and the issues.
Most importantly, the Commissioning Group’s Governing Board is meeting in public at 1.30pm on Friday May 17th at Epsom Downs Racecourse. This is not a meeting where there are many opportunities for public views to be aired, but it is really important that as many people as possible come along. Those who attended the board meeting at Epsom Hospital a few years ago when maternity was under threat will know that a large audience provides real food for thought for the decision makers. So please do come. The meeting is due to last for much of the afternoon, so even if you can’t come at the start come later.
Once we have seen the consultation document in full, I will provide you with more details about planned campaign activities.
Open letter to Dr Claire Fuller
Surrey Downs Clinical Commissioning Group.
I am writing to you, and copying this open letter to your management board, all the GPs in my constituency and all local councillors, in anticipation of the publication next week of the recommendations to be made by the Better Services Better Value review.
I have long argued that our local GPs should be at the centre of decision making about the future of health services in the constituency that I represent and the surrounding area. It is a matter of enormous disappointment to me that so soon after that power has been granted, our local GPs have chosen to acquiesce in a programme that in my view involves cannibalising Epsom and St Helier hospitals to bolster three other London hospitals, leaving our area denuded of services and putting unfinanced pressure on other Surrey hospitals. I would always have hoped that there would have been a proper local discussion, an evaluation of the savings to be generated for the local health economy by consolidating a range of community and other services on the Epsom site, and local decision making. I would also have hoped to see a real attempt being made to see if an innovative approach to the provision of acute services at Epsom can make them sustainable. Instead we have seen clinical working groups where the views of local consultants have been railroaded by their London counterparts. We have seen decisions taken by meetings where there were six people present from St George’s alone, and two from Surrey, and each individual got a vote.
I have always said that, over all the years that I have campaigned for Epsom Hospital, that I would treat seriously any proposals that genuinely enhance the quality of healthcare for the people I represent. I have always intended to support difficult decisions if I truly believed that they were the best options for patients. I am utterly unpersuaded that such improvements are on the table.
My expectation is that later this week BSBV will announce either that Epsom will lose all of its inpatient services, or that it will become a purely elective centre. It has seemed clear to me all the way through that you and your colleagues have believed that in this latter case, a large amount of additional work will flow from London to Epsom and as a result will sustain it as a local centre.
What this assumption fails to recognise is that there is absolutely no obligation on any London hospital or CCG to transfer work to Epsom. All the hospitals will shortly be Foundation Trusts, they have the right to take their own decisions, and patient choice will, in my view, dictate a reality that they carry on doing most if not all of their current work themselves. I do not believe that the proposed elective work will come to Epsom.
I also believe that no thought has actually gone into what happens to the ownership and control of Epsom after all of this. If both hospitals lose their acute services, and one loses all inpatient services, it is hard to see the Epsom and St Helier Trust surviving in its current form. Who then controls the remaining services at Epsom? Who is responsible for its finances? This is a basic question that it is clear no one has thought about at all. It’s quite obvious that the thinking so far about the consequences generally of BSBV has been woefully inadequate.
The doctrine behind the BSBV review also involves a significant transfer of provision from the secondary to the primary care sector. I have yet to see any evidence that the primary care sector in our area has developed a clear strategy to do this. There is no local GP capacity available – indeed I receive complaints about the difficulty in obtaining an appointment with a GP in some practices, such has been the increase in demand for routine GP appointments. Out of hours services are not well regarded. Those practices that offer additional services tend to make use of roving consultants – but those same consultants will be required to relocate to London hospitals and focus more clearly on their needs if the overall levels of consultant cover envisaged in BSBV are to be met. The primary care sector will need to cover a lot of the work currently being done in A&E at Epsom – either on site or in their own facilities. But who is actually going to do the work?
Most fundamentally, you are signing up to a process of change that is unfunded and where deliverability is completely uncertain. Together with all the local authorities affected and the local MPs, Surrey County Council is currently seeking detailed information from all the hospitals involved, both inside and as neighbours to the BSBV process, to establish the cost and availability of funding to do all of this.
The changes will involve a need to invest in extra capacity not just at St George’s, Croydon and Kingston, but also at East Surrey, St Peter’s and Guildford. It is likely that a large proportion of emergency cases that currently use Epsom will go south and not north, and all of the evidence from past changes is that Epsom patients choose Surrey options and not London ones. In maternity alone, the decision to close the units at Epsom and St Helier require capital investment capable of providing for 6,000 births, the equivalent of a large maternity unit at a major hospital. As far as I can ascertain so far, the expectation is that realising the ambitions of BSBV is likely to cost several hundred million pounds – possibly as high as £300m. Supporting this level of investment will probably impose an additional annual cost of capital burden of perhaps £25-£30 million on the health economy in SW London and Surrey. Where is this money to come from? What evidence is there that it will be provided by NHS England over the course of the next few years? Some of it will need to come from Surrey in the form of additional capital for the other Surrey hospitals. Whose budgets will that money and the ongoing cost of capital come from? What happens if you take decisions now which start to impact on the viability of Epsom and St Helier, services start to really struggle, and then the investment funding is not available?
You will know now that the projected deficit for Epsom and St Helier has fallen sharply, to the point that the Department of Health now regards it as one of its lesser financial problems. There is a strong likelihood of the Trust achieving break even within the next financial year, according to its current forecasts.
More importantly, though, wherever the work currently done at Epsom is carried out in the future, you will still have to pay for it. Unless you can deliver cheaper treatment models in the primary care sector very quickly, then you will end up paying the same amount to other acute trusts, whilst the local health economy also has to find a way of paying for its share of the capital spend on BSBV.
So I really do not understand how this will save any money for our area. And the financial problems that seemed to be making a Surrey option for Epsom unrealistic are clearly easing. I recognise that there is a degree of passing of deficit between secondary and primary care – but the way to solve that is to maximise the utilisation of the spend we have got by consolidation of provision onto the Epsom site, and transforming the way the hospital works.
Of course you and your colleagues have rightly argued that patient safety and patient outcomes should be the most important factor in this. But it is far from clear that we will see improvements for local people.
The most obvious area of concern in this respect is maternity. Epsom’s maternity unit, for example, is currently compliant with Royal College Workforce guidelines, and has mortality figures that are well below the national average and crucially well below the levels at Kingston, Croydon and St George’s. In 2010 it had no neonatal deaths and its perinatal death rate was well below Kingston.
Part of the justification for change is to secure 24/7 consultant cover. But the other Surrey trusts are nowhere near achieving this, and so local people are being asked to accept the disappearance of a local service to secure an outcome that might become available in London, depending on staff retention, but will not be available to them in their own county.
Finally, the plans from BSBV are only workable if the London hospitals take on most if not all of the key medical staff at Epsom. Otherwise it is not possible to achieve the kind of consultant cover they are talking about. But at the same time the primary care sector is operating at close to capacity. So where will the staff come from to do the work at Epsom? How can we be sure that what is left will be able to offer any kind of quality staffed service? You will be aware that clinical staff at Epsom have warned that the BSBV proposals in maternity and paediatrics represent a safety threat to patients in their current form.
In short, I remain completely unconvinced that this rushed process has provided any sensible answers for local health issues. The quality of analysis provided by the BSBV team has been poor, and the understanding of healthcare in Surrey limited.
By contrast there is a real willingness, as you saw at the meeting we held at Surrey County Council, for the Surrey community to engage in real discussions about how to make the local health economy work more efficiently and cost-effectively and to find a Surrey option for Epsom – possibly by integrating health and social care on the site.
What we have on the table right now is either an option which removes all Epsom’s inpatient services, or another which simply removes its acute services. Neither appears to offer either obviously better value for money or a guarantee of improved care for the patients who are currently using Epsom Hospital. There is no guaranteed funding for change, and the cost of provision is, if anything, likely to rise not fall because of the cost of capital. Primary care locally does not seem to be ready to take on significant extra responsibilities, and it is far from clear how the future configuration of services locally would be staffed. It looks like an attempt to cannibalise Epsom to help SW London, and will certainly be seen as such by the local community. And I’m not sure that the NHS is remotely capable of handling yet another major reconfiguration in London when there is already so much happening elsewhere.
I can see no benefit to anyone locally in the months of protest and confrontation that will undoubtedly lie ahead if Surrey Downs simply decides to go ahead with the BSBV proposals. It will embroil local GPs across the area in controversy and will distract everyone from delivering healthcare. By contrast an agreement to set aside the BSBV process, or at least to work alongside it and establish a Surrey based working group with a clear brief and a clear timetable to bring forward a viable plan for the future of Epsom would seem a far more sensible approach. This would enable us to explore again partnerships with other Surrey Trusts, the integration of primary and secondary care on one site, alternative business models for the existing acute services, and possible partnerships with the private sector. I am absolutely of the view that such an alternative is deliverable and would provide better security for our local services in future.
I’m really not sure your governing body has fully thought through the consequences of the current process. I don’t doubt the sincerity of the clinicians involved, but the practicalities look rather different. And they are walking into a maelstrom if things continue as they are.
I can only urge you to take a step back.
With best wishes,