PETITION TO SECRETARY OF STATE FOR HEALTH
We, GPs in Lewisham and the other boroughs of SE London, are dismayed by the recommendation in the Trust Special Administrator’s final report to downgrade emergency services at Lewisham Hospital. We urge you to reject this recommendation (No 5), and instead leave distribution of emergency and elective services in Lewisham and Greenwich to be decided by agreement between local commissioners and the future merged Lewisham/ Greenwich trust subject to a sustainable financial solution.
The TSA has ignored overwhelming opposition from the people and from us, local clinicians who should be guiding the shape of local services under the reforms your government have enacted([i]). However, we are heartened that you have said in Parliament this week that no changes will take place without clear clinical local support. You have also re-iterated the pledge previously made by the PM that proposals will be subjected to the four tests for a reconfiguration.
The four tests are not met
The four tests must be met for Lewisham, since the attempted service reconfiguration in this report adversely affects access to emergency services for Lewisham residents only. The Clinical Commissioning Groups (CCGs) of Dartford and the other five SE London boroughs, who represent populations whose emergency and elective services are unscathed by this review, could not be expected to have due consideration or make a valid judgement on the effect of the proposals on the population of a different borough. It is therefore deeply disingenuous to imply, as the TSA has done, that support from SE London and Dartford for the report in its entirety implies a valid mandate to withdraw services from Lewisham.
Test 1: The report does not have support from GP commissioners
Over 1,000 GPs and healthcare professionals from across SE London have opposed the proposals ([ii]), including the Chair (Dr Helen Tattersfield) and all clinical directors and neighbourhood lead GPs of the Lewisham CCG itself ([iii]). Of Lewisham’s GPs, two-thirds have signed a petition opposing it ([iv]), with none in favour. The TSA has claimed the support of the remaining CCGs in SE London, selectively quoting their responses – which have understandably not focused on the effects on Lewisham, concentrating on their own local services. This prescriptive approach that has been taken by the TSA – where local commissioners have no say in the location of emergency services – is not consistent with this test.
Test 2: The patient and public engagement has been flawed
The Ipsos MORI consultation performed by the TSA’s office itself shows over 94% of Lewisham residents are strongly opposed to the loss of the A&E. 50% of respondents in each of the 6 boroughs were opposed to closure of Lewisham’s A&E. The TSA claims to have met this test on the basis that the process took place (Appendix I), although its outcome showed opposition which in the Lewisham public events was vocal and hostile. We note public criticism of the way these consultation events were run.
The TSA has published recommendation for paediatric services in Lewisham which have appeared for the first time in the final report. Therefore there was no opportunity for scrutiny or comment. These new proposals would close the excellent Lewisham paediatric A&E and set up a paediatric urgent care centre, a model which is collapsing at Queen Mary’s Sidcup. No analysis of services and no modelling of proposals were in the consultation. The impact of fragmentation of care on safeguarding of children was not discussed.
Similarly, a completely new maternity option, disallowed for discussion during consultation, has appeared in the TSA’s final report: the proposed midwifery-led unit in Lewisham has not been consulted on. It is inherently unsafe for the deprived and ethnically diverse local population, which has a high and rising birth-rate with a high proportion of high-risk pregnancies who often present late in pregnancy for antenatal care.
The Health & Equality Impact Assessment was not completed before the consultation.
Test 3: The recommendations are not based on sound clinical evidence
The TSA has referred to clinical evidence which supports centralisation of major trauma, heart attack and stroke in specialist centres, which is well-established and is not in dispute. However, the report extrapolates this to claim that better outcomes can be achieved by centralisation of all other emergency medical, surgical and paediatric conditions.
This is false. There is no clinical evidence for this. Subject to clinical quality standards being met, high-quality care can be provided locally in a high-performing hospital for emergencies (other than stroke, heart attack and major trauma) which account for over 90% of all emergencies, particularly in the frail ill elderly population and children for whom local care is particularly important.
No institution in London meets the new emergency standards in full, but Lewisham, like other providers, is currently planning to implement these. The fact that these are not yet implemented is not grounds to suggest that acute services should be withdrawn.
Clinical panels and workshops were held by the TSA’s office and its management consultants. In these, medical models from around the world and the UK were discussed, and used to build an assumption that, if all the benefits were achieved at the same time, the local health economy would be transformed in five years. This was rapidly used to justify the claim that emerged early on that one major acute admitting hospital could be taken out. This became non-negotiable and no alternative models were offered or allowed in the workshops. Dissent was not recorded and no votes on this issue were allowed.
The TSA’s report asserts that the need for emergency care would be reduced by 30% by providing more care in the community. However, there is simply no clinical evidence to back this up. In any case Lewisham Healthcare has already been innovative in working with social services to provide more care at home and avoid admissions in patients with chronic illness. These arrangements would not be replicated if acute services were lost. Similarly, Lewisham Healthcare as a community-integrated Trust has developed networks with GPs, social care and mental health agencies which would be disrupted if acute services are removed. Fragmentation of care would result, and quality and safety would be impaired.
We remain concerned that modelling of patient flows in the report has been flawed. The flow of patients and revenue is likely to follow established referral patterns and transport links, both for emergency and elective services, to King’s College Hospital and Guy’s and St Thomas Hospitals rather than Woolwich.
Test 4 - The plans do not improve patient choice
Withdrawal of emergency services from Lewisham residents cannot be perceived as enhancing patient choice. The report claims that patients can still choose the Lewisham UCC. Although walk-in patients with obviously minor injuries would retain the Lewisham choice, for a patient with an undiagnosed complaint needing specialist assessment or possible admission an urgent care centre staffed by nurses and GPs, would not be a meaningful choice.
The TSA’s claim that the changes increase patient choice by one failing trust becoming three separate provider sites is risible, since the main change is a major hospital closure.
Maternity choice for the large proportion of high-risk’ pregnancies in Lewisham would be reduced by the loss of the current co-located obstetric and midwifery unit at Lewisham.
Local residents need essential services, provided by a high performing Trust
Emergency services are vital for the population of Lewisham, which contains some of the most deprived wards in England. Lewisham Hospital’s new £12 million A&E department opened as recently as April 2012 in response to the need for expanded services. Our intensive care unit has excellent standardised mortality rates ([vii]). Our new birthing centre has high maternal satisfaction. Lewisham Hospital features in the top 40 hospitals in the CHKS rankings for 4 successive years ([viii]).
Closing emergency and maternity services in a successful hospital is not only wrong, and also unnecessary
Destroying a successful hospital by closing vital services is simply not necessary financially and would only make a saving of £12.2 million (which was around the cost of Lewisham’s new emergency department). If nothing is done, South London Healthcare will have a financial gap by 2015/16 of £75.6 million; however, the TSA’s own figures (Figure 47 of the final report) predict a financial gap of just £1.7 million from a breakeven position if five of the six recommendations are accepted (excluding recommendation 5, so keeping acute services at Lewisham). Despite Matthew Kershaw’s statement that no one has offered alternative solutions, Lewisham Healthcare NHS Trust clearly provide alternative solutions in the Trust’s expression of interest for working with the Queen Elizabeth Hospital. These were not pursued by the TSA.
This has an importance beyond Lewisham
The report is an attempted regional reconfiguration, tacked onto the statutory regime for an unsustainable provider, which is being used here for the first time ever. This reconfiguration is centrally-dictated and does not have the support of the local CCG. The administrator perversely recommends downgrading of services at a high-performing and financially-solvent trust to save a separate, unsustainable provider. It will result in harming a healthy hospital to save three unhealthy ones, in defiance of local commissioners. Is this a signal that your government will want to send to the NHS and the public?
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