“Widespread bed cuts, closures of accident and emergency units and even shutting hospitals have been proposed by NHS bosses
A “secretive” plan to reorganise the NHS risks failing patients, a report warns.
Widespread bed cuts, closures of accident and emergency units and even shutting hospitals have been proposed by NHS bosses who are often more focused on saving money than improving care, the King’s Fund think tank says.
Simon Stevens, head of NHS England, has conceded that managers in many areas are not up to the job of implementing his vision for the health service and is warned today that it risks failure in most of the country.
Mr Stevens is attempting to undo Andrew Lansley’s 2012 NHS reforms without the need for another structural reorganisation, and has divided England into 44 areas where local bosses have been told to come up with “sustainability and transformation plans (STPs)” to move care closer to home.
He insists that doing more in local clinics will keep older people with long-term illness out of hospital. The report published today endorses that aim, but says that STPs are the “right thing being done badly”. Short-term savings are being prioritised over long-term improvements as the NHS faces a £22 billion black hole by 2020, it says.
Plans have been drawn up behind closed doors with patients “largely absent” and with little input from frontline staff, the King’s Fund says. Uncertainly over accountability for the plans is hampering the ability to get anything done, it adds. Chris Ham, chief executive of the fund, estimated that a third of plans were likely to succeed, a third had little hope and the rest would need more help.
“I don’t think the deliverability of STPs is something we can be confident about,” he said. “If STPs do not work then there is no plan B.”
Katherine Murphy, chief executive of the Patients Association, said the plans were “more about saving money”, adding: “They cannot axe services in a secretive way and expect the public to be happy.”
Professor Ham said that cutting hospital services was unlikely to work without money for local clinics to replace them. “GPs and district nurses are under massive pressure. It’s unrealistic to expect them without more staff and resources to take on more of the workload,” he said.
About a quarter of the plans have now been published or leaked and many include centralisation or shutting hospital units or cutting beds. In southwest London, one of Epsom, St Helier, Kingston and Croydon hospitals would be shut entirely.
Taj Hassan, president of the Royal College of Emergency Medicine, said that shutting A&E units would be “potentially catastrophic” and put lives at risk. “Furtively producing plans without involving patients is unacceptable,” he said.
Mr Stevens has acknowledged problems, telling NHS bosses last week that councils might need to take over from health service managers. “In some parts of the country the reality is we are short of leadership that is capable of engaging in the task ahead,” he said.
Sir Bruce Keogh, medical director of NHS England, insisted the plans would be “making it easier to see a GP, providing more specialist services in people’s homes, speeding up the diagnosis of cancer and offering help faster to people with mental ill health”.
He conceded that “to realise these benefits some communities might need to make choices about where to put resources and the NHS will need to be clear with the public about the options” but argued: “Claims of secrecy have been overtaken by the fact that we’ve asked that all STPs are now published over the next few weeks.”
Analysis
Most patients would agree that it makes more sense to keep elderly patients well at home rather than letting them tip into crisis and have to go to hospital (Chris Smyth writes).
In essence, this is what Simon Stevens’s “sustainability and transformation plans” are trying to achieve: getting the local NHS to pay more attention to preventing illness, improving mental health and working with social care.
Of course, it is not quite that simple. Nothing brings patients out on to the streets faster than plans for hospital closures. When Theresa May met Mr Stevens for the first time, she warned him not to use the threat of closures as a weapon to try to prise extra cash out of the government.
Often, there are good clinical reasons for shutting poorly performing units. But when so much emphasis is put on saving money, many in the NHS understandably fear this will mean cost-cutting masquerading as better care.
Among the possible cuts…
Southwest London One of St Helier, Epsom, Kingston or Croydon hospital to shut.
Northeast Stockton or Darlington could lose A and E.
Devon Cut 600 hospital beds and A and E, maternity, stroke and children’s services are deemed “not sustainable”.
Northwest London Ealing and Charing Cross hospitals to be downgraded.
Merseyside Merger of four Liverpool hospitals.
Cheshire Downgrade Macclesfield A and E.”
Source:Times (paywall)
East Devon Watch 
I can’t speak for other parts of the country but I have read the local CCG proposals for community care and closing hospital beds and I have attended one of their consultation events.
In Devon, whilst the vision they have might work (or might not) their plans are so half-baked that it is impossible to tell.
I urge EVERYONE to read my comments below which summarise the shortcomings of the current proposals as I see them, and then to think about whether they want to get active and campaign to ensure that any changes are thought through and implemented properly.
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In essence, the CCG’s proposals are based on an analysis that a large proportion of clinical and community beds are filled by patients who do not have a need to stay in hospital which may well be true. They also say that long stays in hospital where patients are e.g. exposed to diseases or don’t have exercise can result in loss of health. Furthermore, people find hospitals unfriendly and aseptic / clinical (which of course from a medical perspective they need to be, but presumably this is meant from an emotional perspective).
The alternative, they say, is to treat these patients in their own homes where they can be comfortable, with medical care tailored to their individual needs.
Which sounds OK in principle, but if you look even the littlest further, you quickly find that these plans are superficial, half-baked and dangerous:
a. Whilst it may be true that some patients can be treated with just simple visits for medical care at home, this is unlikely to be true for all patients (and possibly not true even for the majority of patients) – there is no analysis or breakdown of patient numbers to indicate what proportion of these patients are suitable for home treatment, and what proportion are unsuitable because e.g. they need non-hospital residential care (because for example they can’t care for themselves and don’t have any live-in relatives who are capable of caring for them). There is no analysis of the number of residential care places needed, now whether this care is actually available (which we know it isn’t since they closed the majority of residential homes a year or two ago).
This is a FUNDAMENTAL flaw in their plans and without it being addressed, these plans can only be considered brutally inconsiderate and dangerous.
b. Nor do they include ANY really joined up plans to ensure that patients who need social care at home (as well as medical care) will get it – which seems unlikely as social care budgets have been slashed by the government and county councils just won’t have the money. So whilst hospitals do provide integrated health a social care for in-patients, once they are pushed out to have home medical care, the chances are that they won’t get the social care they currently get in hospital. In addition the CCG talks about a single telephone number for doctors or neighbours or relatives to contact if that have concerns about someone’s health, but there was nothing that said this was a single point of contact for both Health and Social care – nor were DCC’s social services represented on the panel at the consultation meeting – which presumably means that this is not joined up or integrated.
The consequences for vulnerable patients could be dire or even life threatening. See what I mean about half baked.
c. The analysis of the amount of time needed to provide care in people’s homes appears totally inadequate – for example it does not include factors for patients who are immobile and who need 2 people to lift them. Similarly the cost analysis that justifies savings relates only to the staff costs, and does not include e.g. the cost of providing equipment or modifying people’s homes to allow them to live there properly, nor does it include costs for social care that will need to be paid by some other public sector budget. In the end it is all public money regardless of which budget it is in, and what we need is optimised costs across the public sector, not in individual silos.
Common sense suggests that sending individual carers to drive large distances between patients in rural Devon would seem far less efficient that using those same carers to deliver the same services in a hospital where economies of scale can be achieved.
The onus is on the CCG to have done their sums properly, but it seems to many that the estimated costs of properly delivered home care are way too low; and this certainly makes it appear that the CCG intends to implement it with the current cost estimates fixed (in order to make the savings they are saying are driving this) to the detriment of patients.
d. Furthermore, this appears to be a Devon-wide roll-out of the process that the CCG undertook as a pilot in North Devon and which has been an unmitigated disaster (documentation proving this is publicly available – e.g. IRP Torrington referral to Sec of State for Health, STITCH Report on 6 month evaluation, Boyd Report for DCC Health & Well-being Scrutiny Committee, Tucker Report). There is absolutely no evidence whatsoever that the CCG has learned anything from the North Devon pilot but is nonetheless committed to repeat its mistakes across the rest of Devon.
The CCG’s evidence that the North Devon pilots were a success are based on a non-comparative subjective survey asking patients about whether the administration of their home visits was done well – whilst this is important, it is nowhere near as important as knowing that the medical treatments are as effective. The CCG’s proposals do not include ANY comparative clinical studies (or indeed any non-comparative clinical studies) showing that home care is as effective medically as hospital care.
Dr. David Jenner, Chairman of the CCG’s East Devon Committee said that there were clinical studies available and that he had requested them, but that he had not yet received them. Frankly it absolutely beggars belief that the CCG should make proposals when the senior clinicians have yet to see any evidence of its clinical effectiveness.
Without this evidence, for the CCG to call these “efficiency savings” is disingenuous at best and an outright lie at worst – “efficiency savings” implies that you are providing the same quantity and quality of care for less money, however there is no evidence whatsoever to support this and a lot of evidence to the contrary that suggests these are rushed proposals intended to make cost savings without regard to the impact on services / treatment – or what the public would call “cuts”.
e. The CCG has been open about the difficulties they will face in recruiting sufficient staff to deliver home-based care. Social Services departments in Devon often have great difficulty in recruiting even small numbers of staff, so the ability to recruit the large numbers needed to roll out home medical care are very much in doubt. There are no clearly articulated written plans on how to address this; the Chief Nurse of RD&E said that she felt this might be possible to address using the RD&E brand and creating a better career path for such carers, but this thinking MUST be done before the CCG presents its plans for them to have any chance of holding water.
f. Clearly a patient in hospital who develops complications or has an emergency is in exactly the right place for doctors and nurses to deal with these. Equally clearly, a patient at home in a very rural part of Devon is not in the right place for doctors and nurses (or ambulance crews and paramedics) to treat them quickly.
Another thing missing from the CCG’s proposals are any sort of risk assessments to determine whether patients will be put at risk from complications or emergencies by virtue of being treated at home rather than hospital. For the CCG to have ignored this can only be considered cavalier or even negligent towards patient safety.
Additionally, current approach hospital treatment regimens for various conditions have been honed over decades to eliminate avoidable risks. The new proposals for home treatments are very new and have not yet stood the test of time nor had any shortcomings ironed out. Without detailed clinical trials, there is simply no reason to believe that they will be as safe and as risk free as existing hospital treatments, even if they are resourced and implemented properly.
g. There is nothing in the CCG’s proposals describing even the high-level plan for its implementation. Will it be big bang or phased? Will they be closed before home carers have been recruited and trained? Will patients lives be put at risk?
The reason given for this is that they cannot plan until they have decided what to plan for. And of course, when it comes to detailed, concrete implementation plans that is true. But that does not mean that proposals don’t need to include high-level proposed plans that indicate the overall implementation approach, and which demonstrate that the proposals can actually be delivered if they are accepted. Without these plans, we cannot know whether the CCG plans to implement them in a one big-bang approach (which would be a disaster for patients) or in a phased approach with clear gateways showing that the replacement care is fully ready before going ahead.
Given what happened in North Devon and the pressures on CCG’s from government to cut costs in a hurry (and in particular in Devon where the CCG has had a “success regime” of accountants parachuted in to ensure that savings are made in a hurry), it is difficult to let these sorts of omissions pass and trust the CCG to get it right.
h. Even if we assume that the community care proposals are sound, and that some community beds should indeed be closed, there is no proper analysis which shows how many beds should be closed – the numbers have been determined only by saying that East Devon should have the same number of beds per 1,000 people as N. Devon, but of course N. Devon had its community beds savaged only a year or two ago, so this can only be interpreted as a rush for the bottom.
i. The analysis of options as to which hospitals should be closed has been shown to have used the wrong post codes for some hospitals, and seem to have assumed that everyone has a car because they do not seem to have factored in the availability or otherwise of bus services. If they can’t get right even the part of their plan that has been analysed in detail and which has been articulated the most clearly, what trust should we put in those parts of their plan which have huge, gaping holes in them.
j. The NHS is legally bound to consult the community on proposed changes – and indeed were found to have acted illegally in N. Devon when they failed to do this. However, the current “consultations” are themselves flawed, because they assume that community beds should be closed without consulting on that assumption, and then ask only which beds should be closed not whether they should be closed or how many should be closed.
FINALLY, I should stress that I gleaned the above points from the CCG proposals without having delved into the details, and without any health background. Imagine what other details still lurk in these proposals waiting to be found by someone with more time and more health expertise.
And of course, this is just the tip of the iceberg – the current proposals will only (at best!!!) save a fraction of the current under-funding, with many more similar proposals to come as part of the Strategic Transformation Plans.
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The bottom line is that the CCG’s proposals are seriously incomplete and, without a great deal more thought and planning, are likely to put patients at serious risk.
If you are reading this, please don’t leave it to other people to campaign to stop these cuts from happening – these cuts will affect you directly, and if you don’t do your own part in fighting them you may live to regret it (or indeed not live to regret it).
Please join up with a local campaigning group (like the East Devon Alliance) to join the fight to stop these cuts.
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This is an excellent analysis of the absurd and damaging proposals that are destined to ruin so many lives if they are implemented. We must spend more money on our NHS: it is our service and we must fight to retain what is ours. It is not the possession of those who favour, and would benefit from, privatisation.
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