Agenda item

 

Southwark LINk has sent the enclosed document in response to the scrutiny chair’s call for evidence on the Trust Special Administrator’s (TSA) draft recommendations.

 

 

5.1  The chair welcomed Mathew Hunt, Trust Special Administrator, Stephanie Hood, Director of Communications, and Dr Jane Fryer, Medical Director NHS South East London, and invited them to take questions on the Trust Special Administrators (TSA) draft report.

 

5.2  The chair opened the question and answer session by asking how King’s Hospital would cope with the proposed closing down of Lewisham Hospital’s Accident and Emergency (A&E) department and maternity department; particularly given that King’s maternity department recently closed down for four days as it had reached capacity. The Trust Special Administrator responded that they have done some modelling on both travelling and patient choice and the modelling does demonstrate that it would affect King’s. He explained that if the draft recommendations were taken forward, then the report identifies that money would be needed to make the changes and that there will be time to make the adjustments. The Trust Special Administrator added that the report is not saying that the present level of activity would carry on – community care is there to prevent people going to hospital and improve discharge. Additional capacity would be provided by changes in hospital provision and in community care.

 

5.3  The Medical Director added that the modelling predicted that 37% of “Blue Lights” would go to King’s and that the TSA process recognises that the hospital cannot absorb this in its present configuration. She went on to comment that there are two maternity options for Lewisham Hospital and that the safety issues surrounding deliveries posed by each possible plan are  being deliberated on. She reported that there would also be a need to consider the neo natal provision.

 

5.4  The Medical Director and Trust Special Administrator noted that this is a three year transitional plan; the first year will have a full business case and the following two years will have a high level plan The chair queried the level of detail in the plan and asked if the proposals are being tested with people working on the ground. The Medical Director reported that they had met with the members of the governing bodies of the trusts that are affected and that there is an external clinical panel. The maternity side has representation from the Royal Collage of Nurses and a focus group has been held with women with babies and those likely to have babies soon. The Trust Special Administrator added that there is also an independent Competition and Collaboration panel. He explained that the full report will be ready by 7^th January and then this will be scrutinised by the Secretary of State and he will take advice from senior Department of Health officials including Bruce Keogh, Medical Director of the NHS Commissioning Board, and Sir David Nicholson, Director of the NHS Commissioning Board.

 

5.5  A member then asked the Medical Director to confirm that the reports estimate that 37% percent of the emergency cases seen by Lewisham Hospital would go to King’s, rather than the 37% of overall activity, so around 25 % of the current emergency total. He asked the Medical Director how many additional ambulance journey miles would take place because of these changes. The Medical Director said she did not have information on ambulance journeys to hand but she could find out. She confirmed that Lewisham Hospital think that it would continue to see 70 - 80 % of A&E cases as an urgent care centre. She went on to explain that some of the blue light cases would currently go to the stroke hyper acute unit at Bromley or King’s, and similarly a heart attack would be seen in a specialised centre, and noted that there are good examples of how if you concentrate clinical practice and standards there are better outcomes for patients.

 

5.6  The Lambeth scrutiny chair commented that the report’s draft recommendations for maternity units appeared to propose four full units and one not quite a full one at Lewisham. He went on to say that, while he would have thought that it is possible to filter out some of the higher risk births, surely this would not be possible for all deliveries. He went on to voice concerns that more ambitious medical practitioners might not want to work at unit which did not offer the full compliment of obstetric and emergency back up services. The Trust Special Administrator commented that all five, if this option is taken forward, will be consultant led, and went on to observe that none of the present maternity units meet all the maternity standards now.

 

5.7  The Director of Communications commented that the draft recommendations propose four maternity units at all admitting (A&E) hospitals and the possibility of a fifth at Lewisham, and this would be obstetric led. She went on to note that this unit presently takes 4000 live births , and only around three a year have needed wrap around services, and these could be dealt with if there are appropriate protocol and management of risk that would enable the  transfer of these patients. A member asked if this five-model proposal had support and the Director of Communications confirmed it did. The member suggested that might be qualified support given the limited options. He went on to query if the Lewisham Hospital’s maternity proposal would be clinically safe and financially sustainable over the longer term, however, he noted that 4000 is a considerable number of births to be redistributed over the health system. He asked if the downgrading or closure of the maternity unit would have an effect on the Evelina children’s hospital at St Thomas’ and noted that there is a problem around neo natal capacity generally in London.

 

5.8  A member asked the Trust Special Administrator how it was decided that the scope of this process would encompass the South East London healthcare system and six boroughs of Greenwich, Bexley, Bromley Lewisham, Lambeth and Southwark, and who took the view; was it the Secretary of State or was it was it his decision. He also asked why the whole of London was not considered and asked for confirmation that the process is for five years.

 

5.9  The Trust Special Administrator responded that the Secretary of State took this decision on the basis of a consultation exercise that he commissioned with the three boroughs most affected (Greenwich, Bexley, Bromley), the South East London cluster and Health Authority London. The consultees responded that a truly sustainable solution would need to look at the Private Finance Initiative (PFI), productivity and wider connectivity of the South East London healthcare system. The respondents considered that the problem of South London Healthcare Trust could not be solved independently. The Trust Special Administrator emphasised that his accountability is to deliver a solution for South London Healthcare Trust and this is the starting point of the process, under the direction,  and in consultation with the Secretary of State. He explained that that the solution proposed would set out a plan for five years, with a three-year change process. This, he said, would deliver a strong and sustainable system that any additional changes, as a result, for example, of workforce changes or clinical changes, could adapt too.

 

5.10  The Medical Director added that that if we had not been here because of money then the South East London healthcare system would have needed to make changes, particularly around Accident and Emergency and maternity services, and it would have been necessary to have these conversations.

 

5.11  A member commented that he has looked at the evidence, which is quite strong, and asked if this is the major change process envisaged for the next five years. The Trust Special Administrator commented that five years is quite a long time and it is not anticipated that a similar conversation would be needed for some time. He went on to emphasise that a loss of around £55 - £65 million pounds a year by South London Healthcare Trust was not sustainable.

 

5.12  A member asked if the Trust Special Administrator thought that including the wider London system would have been helpful. The Trust Special Administrator responded that this it is out of his remit, and noted that there are other pieces of work being done in London to look at different aspects of the health service.

 

5.13  A member asked about the clinical governance model being employed around the elective centre,  pre/post operative care and if computer systems would be able to talk with each other. The Trust Special Administrator explained that care would be delivered locally.  He responded that there were several computer systems at South London Healthcare Trust that did not integrate; and one of the early priorities of the new organisations formed will be to connect together hospitals and services.

 

5.14  He noted that 70% of elective operations can be done on a day care basis, and that the elective centre will be a purely planed centre, and so not at risk of cancellations. He noted that there is an elective centre at Guy’s Hospital and that the TSA process is recommending an elective centre at Lewisham Hospital. The Trust Special Administrator commented that is he is planning further work on the clinical governance model. He said it is planned that surgeons from other trusts would come to this site, feel a sense of responsibility and purchase services available. A member asked for confirmation that the elective centre would have surgeons coming from different trusts and organisations. The Special Trust Administrator confirmed this was the plan and noted that this model has been used successfully, so there is an existing practice to draw from, and that initial conversations and discussions have taken place.

 

5.15  A member said that she thought that the Trust Special Administrator had come up with a constructive set of recommendations that will save lives; however, she asked if there were any recommendations that were put in with a heavy heart. She went on to enquire if it would have been helpful to include social care within the change process. The Trust Special Administrator commented that we are still in a consultation process, that there was a challenging session last night at a public meeting in Lewisham, and that the TSA administrator team are not immune to the comments. He went on to explain that the draft recommendations form a set of changes that are broad and challenging. They are not straightforward and without risk, however he said that he believed that they are a good set of recommendations that made the best possible case for moving forward.

 

5.16  The Trust Special Administrator agreed that the TSA administrator team could have gone broader and looked at health and social care. He noted the importance of other partners in the voluntary and independent sectors, and the local authorities, and the importance of the Health and Wellbeing Boards.  The Director of Communications commented that this is response to a difficult situation and not a traditional NHS solution. She went on to note that Public Health elements are just as important and more investment is needed in this area.

 

5.17  A member noted that these draft recommendations as very substantial solutions and most of the impact is going to fall on Lewisham Hospital and King’s Collage Hospital, which are not failing organisations. He went on to remark that there are legacy issues of both debt and people that will not be easy to resolve, however the report says little about risk. He also enquired about the estimate of 40 minutes from King’s to Lewisham A&E via public transport. Lastly, he asked about the financing of the elective care centre and the impact on King’s.

 

5.18  The Special Trust Administrator said in his view the biggest impact was on South London Healthcare Trust members of staff. He noted that while there was a significant impact on Kings they had received representations from King’s College Hospital Trust (KCH) that had led to KCH being identified as the preferred provider to acquire Princess Royal University Hospital (PRUH). He noted that Lewisham Hospital is not a failing trust, but that emergency standards are not being met by any of the providers. He acknowledged that there are people who vehemently disagree with the proposal however to close the Lewisham Hospital A & E, but change is needed and this is the opportune moment. He said the  major risk, in his view, was to keep the status quo. The Director of Communications commented that planned change would allow for financial stability from which will flow clinical stability.

 

5.19  The Medical Director commented that this is a clinically led process to achieved standards around emergency and urgent care. The number of admitting departments needed was considered in order to reach these standards. She reported that each of the A & Es were considered and a range of factors were considered, including travelling time and the evidence is considered in some detail in the report.

 

5.20  The Medical Director reported that the elective care centre will use a partnership model and that all consultants and activities would stay connected to the host organisations. She noted that there would be costs and that these would be owned by that system. A member asked how the elective centre would be funded and the Medical Director explained that there would need to be capital development and this would be given an additional allocation of money. A member asked if the IT system will be compatible and if patient records will marry up. The Trust Special Administrator agreed that connectivity is important and he would like to see better integration in the new organisations going forward.

 

5.21  The Special Trust Administrator was asked why there was a second option in the report for there to be procurement process for PRUH, which could lead to private organisation taking over PRUH. He responded that the draft report contains options and the final report may contain a more positive recommendation that KCH take over PRUH. The member noted that the detail of the report flags up the pension liabilities. The Trust Special Administrator responded that the main issues are the passion from KCH to acquire PRUH and the connectivity across South London, and that the pension liabilities are not a big issue.

 

5.22  The issue of additional resources was raised and the Trust Special Administrator was asked where these would come from. He responded that there would be additional resources that would not come from within the current budget.

 

5.23  The chair thanked the TSA team for attending and the Trust Special Administrator explained that the consultation responses he anticipated from scrutiny, and other bodies, would be published on the website alongside the final report. 

 

5.24  The chair of Lambeth scrutiny invited Kate Hoey, MP for Vauxhall, to speak briefly on the TSA recommendations and the merger of King’s Health Partners (KHP). The MP began by commenting that she is representing all five of the local MPs in calling for the super trust merger of KHP to be put on hold as the TSA draft recommendations would have a big impact on Guy’s &  St Thomas’ and KCH. She went on to say she appreciated the openness that the Trust Special Administrator has shown.

 

5.25  The MP voiced concerns with the drive for the merger of KHP, as she said it did not appear to be a bottom up process, but instead led by the senior executives of the respective trusts. She said that, so far, she has seen little that will improve the health care of her local constituents and that all the MPs have called for an independent report, which has been commissioned, and she looks forward to considering this.

 

5.26  The MP commented that she does not want to see elective care only available in Lewisham Hospital. She closed her comments by emphasising that while negotiations were ongoing regarding KCH acquiring PRUH it was not sensible to precede with the merger plans for KHP and urged these plans be put on hold until after the Secretary of State has made the final decision. The Trust Special Administrator commented that the KHP merger is not mentioned in the report because the TSA process had a very specific brief.

 

5.27  The chair invited the Kings Collage Hospital (KCH) Trust representatives, Tim Smart, Chief Executive, and Michael Marrinan, Medical Director, to give evidence on the TSA draft report. They reported that they have contributed to the clinical advisory board as part of the process. The Chief Executive explained that KCH have felt for some time a commitment to finding a solution. He explained that this is partly self-interest, the trust has been losing £65 million a year and this is money that will not reach other parts of the NHS, but also KCH is part of Kings Health Partners (KHP) who consider ourselves to be system leaders, as they are an Academic Health Science Centre.  He reported that KCH / KHP submitted an interest in acquiring Princess Royal University Hospital (PRUH).

 

5.28  The Chief Executive remarked that although KCH has successfully delivered on its targets for sometime the organisation does on occasions feel close to the precipice. He reported that their had been some difficult conversations concerning A & E and that if Lewisham Hospital’s A & E is closed King’s think that the hospital will see a higher number of admissions than the report’s estimates.

 

5.29  The chair asked if King’s had the physical space to expand its services and the Chief Executive said that unless King’s can acquire the EDF site then there would be no additional room and this could lead to additional waiting times and more cancelations of operations. He went on to remark that the acquisition of PRUH could allow King’s to decompress and this makes the expansion of their services more sustainable. The Chief Executive explained that KCH /KHP are putting together a business case for 13 December to acquire PRUH and this will be submitted to Monitor and the TSA. He explained that Monitor may take sometime to respond. He commented that in terms of the populations of King’s this is the least worst course of action and that this is not something that KCH would choose to do.

 

5.30  The chair asked how the proposed merger of KHP is progressing, given the implications of the TSA report, and the Chief Executive responded that KHP are not spending significant amounts of time and money during the TSA process.

 

5.31  A member asked what would be the impact of acquiring PRUH on KCH governance and the Chief Executive  responded they KCH would need to change their governing document, and they may consider their non-executive directors, however two already are representative of the PRUH local population so significant change of the directors is not anticipated.

 

5.32  The KCH Medical Director commented that KCH agree that concentrating emergency services can improve clinical outcomes. He said that King’s have the clinical capacity, with equipment and staff; however, physical space is an issue. He reported that some services could relocate to Guy’s, St Thomas, and PRUH.

 

5.33  A member referred to the proposed merger of KHP and voiced concerns that the uniqueness of each organisation might be lost and a possible consequence could be that each takes on the worst practices of each. 

 

5.34  The Chief Executive responded said that the merger will need to take the best of all three. He commented that the most important benefit for local people would be the tying together of physical and mental health and noted that mental health is hardly given a mention in the draft TSA report. He reported that the rheumatology department have a psychiatrist present and they have started to include a question about how patients are feeling. Because of this they have diagnosed that 30% of patents are clinically depressed, but 75% of these had been undiagnosed. He reported that this was a significant healthcare gain. The KCH Medical Director added that KHP allows clinicians to support each other’s specialities.

 

5.35  The Chief Executive was asked by a member if he saw the proposed acquisition by KCH of PRUH as a forced marriage and he responded that KCH could clearly have declined, however there has to be a solution and the taxpayer will benefit if PRUH is run as efficiently as King’s and Guy’s & St Thomas’.

 

5.36  A member referred to the lack of physical capacity to expand at King’s and asked if KCH still have an interest in Dulwich Hospital and the Chief Executive responded that it is no longer owned by the KCH Trust.  The Medical Director said that it is possible that this location could be utilised as a dialysis centre.

 

5.37  The Chief Executive was asked to expand on the pressure that A & E at King’s is experiencing and he explained that King’s until recently has seen around 25 to 30 patents a day, however this is now about 40 a day.  The level of attendance has stayed as high as last winter. He explained that the average stay is 2 days; however, an 80 year old can stay much longer. This can have a knock on effect on elective care.  He ended by saying that he thinks that the number using A&E could go up to 50 - 60 if Lewisham Hospital A&E closes. The KCH Medical Director reported that King’s do not meet all the clinical standards, and no hospital in London does, however King’s and St Thomas’ hospitals are closer. He commented that the earlier an emergency patient sees a consultant the better and that the A & E proposals have clinical value.

 

5.38  The chair then invited representatives from Guy's & St Thomas Trust; Jackie Parrott, Director of Strategy, and Dr John Scoble, Deputy Medical Director, to give evidence. They explained that they also sat on the clinical advisory panel of the TSA. The Director of Strategy noted that they could take on extra maternity cases; however, they would need additional capital investment. She reported that all local hospitals sometimes have to cap their maternity admissions to prioritise. She noted that there are additional implications on paediatric services if maternity at Lewisham Hospital closes and the report is silent on this.

 

5.39  A member asked if Guy’s and St Thomas' Trust thought that their urgent care centre at Guy’s Hospital was really working and they responded that they thought it was. They went on to note that the Lewisham Hospital’s proposed urgent care centre would do more , however they questioned the modelling over numbers and said that they thought more anticipated patients would use King’s and St Thomas’ hospitals A & E.

 

5.40  The chair then invited Andrew Bland and Andrew Eyres, Southwark and Lambeth Clinical Commissioning Group executive officers, to comment on the TSA proposals. The CCG officers commented that no change is not an option and went on to comment that they would like to be assured that the patient flows are well planned out and that the plans for community care are important and that patient’s choice will be optimised. They supported the move to treatment closer to the home and greater specialisation in hospitals, and noted the successful work on stroke centres.

 

5.41  A member asked about travel times to the proposed elective surgery centre at Lewisham and asked if patents and families will have the resources. The CGC officers remarked this raises important issues of quality and inequality, and that sometimes there is a trade between the need to travel and quality. The chair of Southwark CCG commented that the transition process is short and it is important that this is done well. A member asked if the CCG are consulting with their membership on the TSA proposals and the CCG executives responded that they are not holding specific events, as this process is led by the TSA; however, they are raising the issues at their usual events and passing on comments to the TSA, where appropriate.

 

5.42  The chair then invited Patricia Mobley, local resident, to give evidence.  She explained that she is the ex-chair of Guy’s and St Thomas’ Trust board. She spoke about the planned large elective centre at Lewisham Hospital and noted that Guys and St Thomas’s elective care is second to none, and that urgent and elective were separated about a decade ago. She raised concerns that Southwark and Lambeth residents would have to use the elective centre Lewisham Hospital. She commented that the culture of the teaching hospital at Guy’s is important, and that KHP is driven by the high clinical standards of an Academic Health Science Centre.

 

5.1  A member noted the success of concentrating clinical specialisms, such as heart centre, stroke and cancer care and suggested that elective care may benefit from this too. Patricia Mobley responded that a teaching hospital allows a good mix of complex and straightforward cases and, moreover, Guy’s has seen significant investment in its elective centre.

 

RESOLVED

 

The committees both resolved to consider the evidence received and draft written submissions for the Trust Special Administrator.