NHS for Sale: Myths, Lies & Deception (30 page)

So however much the plans are said to be the work of ‘clinicians’, and are presented as improvements under the heading
Shaping a Healthier Future,
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in fact they are driven first and foremost by financial concerns – and the attempt to curb spending.

Much more recently, CCGs in the five counties of what was formerly the East Midland Strategic Health Authority have identified a combined savings target for health and social care over the next five years of more than £1bn – almost 20 per cent of the current budget – while local trusts already faced deficits of almost £150m in 2014-15. As the pressure mounts for cuts and closures – even contemplating reducing sprawling Lincolnshire with its scattered population and inadequate road network to just a single A&E – pressures and demands on frontline services continue to increase, and the numbers of more vulnerable older people are growing even faster than the general population.
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In the summer of 2010, just weeks after the election in which he and David Cameron had made so many promises, Andrew Lansley travelled to the threatened A&E at Chase Farm Hospital in Enfield to make his announcement of a ‘moratorium’ on closures of A&E and maternity units. He pledged to halt the ‘top-down process that forces closure’, but made it clear he offered a stay of execution rather than a full reprieve. He refused to guarantee the A&E department would be saved, or say how long the moratorium on cuts would last. He told reporters: ‘I can’t rule out change, I can’t rule out A&E closures. But we will stop forced closures. We will take away all decisions not clinically based, which don’t conform to patients’ needs.’

Well at least the first two statements were correct. Closures of local services including A&E were by no means ruled out – as long as they could be claimed somehow to comply with Lansley’s minimal new preconditions.

The management were never fooled, and the promise didn’t last too long. Barely was the ink dry on Lansley’s authorisation of the moratorium before it was clear that the delay would be just a couple of months across the summer of 2010.

So while the hotly contested closure of Chase Farm’s A&E was postponed for a while (although it eventually closed its doors at the end of 2013) in south-east London, Queen Mary’s Hospital, Sidcup, whose A&E and other services were threatened as part of a desperate plan to restore financial viability to the South London Hospitals Trust, was the first of many that were still set to lose most of their services.

This was despite opportunist claims by the local Tory candidate, James Brokenshire, made just before the election
to have secured a pledge from Lansley that St Mary’s would be reprieved. The claims were soon discredited. By the autumn of 2010 key services were already closing down, in the beginnings of a process that has now left almost no services on the site.

A similar fate would have befallen King George’s Hospital in Ilford if the assumptions on which the closure was supposed to be manageable had not been so disastrously and visibly wide of the mark. King George’s has for years been part of the Barking, Havering & Redbridge NHS trust, which since 2006 has been struggling unsuccessfully to cover the inflated costs of payments on its PFI-funded £226m Queen’s Hospital in Romford.
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King George’s sits on a site two thirds of which could be sold off. This hospital has no PFI bills attached; closing it has always been above all about saving money and relieving the financial distress of its parent trust.

But Queen’s Hospital (as critics had warned) had been built with too few beds, and the Trust has been in such dire financial straits that it was unable even to afford the staff to make use of the whole of the costly new building, leaving a whole floor closed at considerable expense, while the remaining beds ran at full tilt. The only factor saving the Trust from total meltdown was the availability of beds at King George’s – beds that would be axed if the plan to shut down most of the busy 20-year old hospital, bulldoze two thirds of the site and sell off the land were carried through. The closure has been postponed to 2015, but still no real plans are in place for what would happen to the patients displaced
when it goes.

Of course, none of the closure plans in London or elsewhere are ever presented as closures. Instead, they are painted up as ‘reconfigurations’ to centralise services in other hospitals, where teams of eager consultants will toil seven days a week, 24 hours a day. A diplomatic silence always obscures the fact that few of these new ‘centres’ would in reality have any of the investment in resources and extra beds they would need to deal with the additional caseload if another local hospital was closed.

The spoof
Briefing for Cynical Commissioning Groups
on ‘how to get away with it’ emphasises the need to give the impression that the axed services would be replaced by something different but better:

Imply – or even promise – you will replace hospital care with a range of services ‘closer to patients’ homes’ or ‘in the community’. Never mind the fact you’re closing the nearest hospital, or that there is no evidence these services can replace A&E – or that there’s no money to pay for them.
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In fact, hardly any of the fabled community-based or primary care ‘alternative settings’ for care actually exist. Time and again a close reading of strategic plans for reconfiguration reveals the same sad story of deception: there are no staff, no premises, no plan, no money and really no political will to establish these services – which may well prove more expensive and less efficient than the hospitals they are supposed to replace. Local GPs, mostly keeping their heads down and ignoring the reconfiguration process, hoping that the worst won’t happen, are in many cases already struggling,
and their services in some cases are less than consistently good. There is little chance that they could absorb the vast increase in workload that the planners are proposing to dump onto them with the closure of hospitals.

The spoof
Briefing
urges CCGs:

Wherever possible avoid offering any concrete plans for alternative services. You are trying to save money, not spend it. Your only concrete plans, with timescales for implementation should be your cuts and closures. Remember it’s always easier not to make a promise than to break one.

Many areas are struggling to recruit and retain GPs – and the shortage of these and other crucial staff, such as district nurses, seems set to worsen. It’s all a big exercise in deception – in some cases the self-deception of well-meaning bureaucrats accepting some spurious ‘evidence’ of policies they are being pressed to implement, and hoping it will all turn out for the best. In other cases there is more cynical deception in the management offices or consultancy firms where the spurious figures and claims originate. Whatever the motivation, the consequences of half-baked plans are the same: gaps in care, failing services and patients put at risk.

The
Francis Report
in February 2013,
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learning one of the key lessons from the Mid Staffordshire Hospitals debacle, spelled out the duty of directors and senior managers to point out when resources are inadequate to deliver safe and satisfactory services, rather than muddle on inflicting cuts which make it impossible for professional staff to do their jobs properly. This duty should apply with equal force to commissioners who find themselves driven towards policies
by financial constraints. Sadly too many of them seem to feel they can simply pass their problems on to the frontline providers, who have no line of escape, and who wind up carrying the can when staff shortages or delays in treatment result in harm to patients.

NHS London’s
Integrated Strategic Plan
argued that five interventions could between them save up to £3.1bn.
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Many of these consist of delivering less care, or seeking to bury the identifiable costs of delivering hospital services in a general heading of community or primary care.

The proposed interventions were:

• Reducing the cost of services delivered in the community.
  
• Providing more care in the community and less in hospitals.
  
• Stopping clinical interventions which NHS London argues ‘have little or no benefit to those receiving them’ – including ‘some joint replacements’ (although no more detail is offered).
  
• Proactive care for people with long-term conditions, reducing the need for hospital admissions.
  
• Prevention to reduce the risk of ill-health.
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In practice the evidence for cost savings from developing GP and community out of hospital initiatives is very limited. Research published in 2012 surveying all out of hospital initiatives failed to demonstrate savings.
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Also in 2012 an analytical paper in the
BMJ
by Professor Martin Roland and Gary Abel
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questioned the received wisdom that hospital admissions could be reduced and costs cut by improving primary care interventions, especially those aimed at high risk patients (whose chronic health problems often lead to them being pejoratively dismissed by NHS bureaucrats as ‘frequent flyers’). Among the bevy of myths dispelled by this study is the illusion that high risk patients account for most admissions, or that case management of such patients could save money:

[M]ost admissions come from low risk patients, and the greatest effect on admissions will be made by reducing risk factors in the whole population….

… even with the high risk group, the numbers start to cause a problem for any form of case management intervention – 5 per cent of an average general practitioner’s list is 85 patients. To manage this caseload would require 1 to 1.5 case managers per GP. This would require a huge investment of NHS resources in an intervention for which there is no strong evidence that it reduces emergency admissions.

Roland also points out the difficulties of assessing the effectiveness of those interventions that have taken place because of fluctuations in numbers of admissions even among those at high risk. Some of the interventions that have been piloted, providing case management for high risk groups of patients, have proved not only ineffective, but to result in increased numbers of emergency admissions – possibly because the increased level of care resulted in additional problems being identified. Indeed three trials of
interventions have had to be abandoned because of increased deaths among the patients involved. Roland warns that an additional unintended negative consequence could result from GPs feeling under ‘excessive’ pressure not to refer sick patients to hospital. And Roland criticises the failure of many plans aimed at reducing hospital admissions to consider the role of secondary care, and improved collaboration between GPs and hospital colleagues.

Promising to locate more and more services in smaller, community settings ‘closer to home’ makes good soundbites, especially when this is being used as a smokescreen to divert attention from the closure of convenient nearby hospitals, requiring many patients with more serious problems to travel even further from home. But there are real questions to be asked about the costs and efficiencies involved, and availability of essential, but sometimes scarce professional staff. Most would agree that neighbourhood access to MRI scanning, for example, or proton beam therapy makes little sense. These resources need to be shared across much wider populations to ensure that they are adequately used and staffed by appropriately skilled staff.

For similar reasons there were questions over the viability of including X-ray imaging in Lord Darzi’s planned polyclinics, which would raise the need for larger buildings, with lead-lined rooms and costly equipment, and for radiographers and radiologists who are in short supply. Likewise it’s not clear why NHS England CEO Simon Stevens’ idea of GP practices employing hospital consultants makes any financial or organisational sense.
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Highly specialist consultants would be obliged to spend time dealing with much smaller hyper-local lists of patients rather than being based together with other consultants (and training junior doctors) in hospitals
covering larger populations, developing multi-disciplinary teams.

Is it a good use of the time of highly skilled professional staff for them to be travelling around from one GP practice or relatively small health centre to another to see small groups of patients, rather than working continuously from a central base – and one that already exists, and is known to patients? How does it make financial sense to equip small-scale local health centres and GP surgeries with the costly equipment needed for even the most basic consultations, when it would be used only occasionally?

There seems to be a contradiction between wanting to save money and work more productively on the one hand, and the consumerist idea of specialists running round to deal with individuals and small groups of patients on the other. Given the economic constraints that hang over the NHS and the absence of the long-promised new expansion of community-based services, it seems the utmost folly to move to a less efficient, more fragmented system that could cost more without enhancing the quality of patient care – at the same time annoying whole communities whose hospitals and local services could be put at risk in the process.

This chapter has referred to evidence, academic research conducted for the NHS, and to practical examples to underline the fact that the case for hospital (and in particular A&E) closures has not been made. Instead of evidence, commissioners and hard-pressed hospital trusts have time and again relied on assumptions about care in the community which are either unproven, or worse, downright wrong. They have made selective and inappropriate use of statistics,
and drawn inappropriate conclusions from the experience of well-resourced and widely accepted centralisation of specialised stroke and trauma services – in the hope of persuading local people to accept unpalatable loss of local access to emergency services. In misleading strategic documents and Business Cases they have repeatedly tried to pass off generic arguments for reconfiguration as tailored to ‘local’ circumstances, and put forward at best vague future aspirations to expand community and primary health services as sufficient grounds for short-term closure and downgrading of actual services.