Full text of letter from doctors' leaders in Redditch and Bromsgrove

The full letter from the governing body of the letter from the governing body of Redditch and Bromsgrove Clinical Commissioning Group to local doctors:

Future of Acute Hospital Services in Worcestershire

9th June 2015

Briefing for Membership Practices from Redditch & Bromsgrove CCG Governing Body GPs

It has been the consistent position of our CCG that urgent care capacity must be maintained at the Alexandra site due to the lack of capacity at Worcestershire Royal Hospital (WRH) and elsewhere.

In January 2014 the Independent Clinical Review Panel (ICRP) chaired by Nigel Beasley agreed with this assessment: the panel made a series of recommendations called Modified Option 1, to which all NHS organisations including Worcestershire Acute Hospitals Trust (WAHT) and the 3 Worcestershire CCGs signed up.

The main difference from the previous ‘Option 1’ model was the inclusion of an Adult A&E with on-site ED consultants at the Alexandra, supporting the acute medicine service. (The full ICRP report can be accessed at the following link: http://tinyurl.com/mhvub9u ). The report makes clear that without an Adult ED, 6000 frail elderly patients in ambulances per year would be diverted elsewhere.

There are currently 55000 attendances annually at the Alex ED: case analysis has suggested a maximum of 2/3rds of cases might be dealt with by an MIU and Urgent Care Centre, leaving 18,000 cases per year requiring transfer if the A&E closes at the Alex. The associated crippling ambulance costs of patients being taken elsewhere would overspend the CCG budget and require investment of large sums on transport rather than focusing this budget on improved patient services and treatment.

Nigel Beasley has made it clear that it was up to us locally to determine how to provide the recommendations within Modified Option 1. Three Task and Finish Groups produced a proposed model to implement Modified Option 1, based on the services that the WAHT specialists who attended the meetings said could be provided by WAHT.

The proposed model came with a list of unresolved risks – the main risk related to Deanery approval & potential loss of training grades in Emergency Medicine. Attempts to resolve this via a meeting with the Deanery actually confirmed this as an insurmountable risk. The other major unresolved issue was surgical cover. West Midlands Clinical Senate (WMCS) was asked to review our proposed model and provide a judgement as to whether or not it was clinically safe and sustainable.

The WMCS report has now been finalised and signed off. The report supports and endorses the recommendations from the Jan 14 ICRP report around Modified Option 1. We now have 2 independent reports from national experts both concluding that an A&E with ED consultants must remain at the Alexandra site.

However, WMCS has major concerns about the proposed model put forward for review and does not endorse this as a clinically safe and sustainable model. The report explains the reasons for this in great detail and we are urging WMCS/NHS England to publish the final report without further delay.

Joint Services Review

The JSR was set up to find a clinically and financially sustainable model for WAHT. It focussed purely on Worcestershire, ignoring the proximity of the Redditch & Bromsgrove area to South Birmingham, or the potential role that neighbouring providers could play in the provision of acute hospital care within Worcestershire. The WMCS report now confirms that we do not have a clinically sustainable model for WAHT. Furthermore, with a large historical debt, a deficit of £25.9m in 14/15 and a planned deficit of £31.1m for 15/16, there is no sign of a financially viable model for WAHT either.

So where do we go next?

Redditch & Bromsgrove membership practices have repeatedly called for all possible options to be examined, and have written publically to the Governing Body to this effect. However, there has been no local support from NHS England, the TDA, or the other Worcestershire CCGs for alternative options to be worked up, and our CCG has therefore been unable to pursue this to date, focussing instead on the proposed model for WAHT to provide Modified Option 1. The WMCS report is a watershed in this process, as it has concluded that the proposed model is not safe or sustainable.

Can’t we just tweak the proposed model?

The resignation of all 4 ED consultants from the Alexandra in February followed by publication of their resignation letter (http://www.worcsacute.nhs.uk/news/update-from-the-board/ ) made clear the depth of problems with the proposed model, and this has been confirmed by the WMCS report. WAHT has managed to recruit enough ED consultants at the Alex for the Deanery to approve training status through to May 16. However, WMCS has confirmed that our proposed model for an Adult ED at the Alexandra site provided by WAHT is not clinically safe or sustainable.

Therefore, if centralisation of maternity/paediatrics/emergency surgery goes ahead (either after consultation or via closure on safety grounds), we will be left with an Adult ED which is not sustainable and under threat of closure, which would result in very significant flows of acutely ill patients to WRH and north to the QE. We have noted with great concern the already poor performance at WRH, and seen the effect of the downgrade of Stafford Hospital on the performance at North Staffs, and we are determined to avoid a repeat of that scenario in Worcestershire. Unlike the situation in Staffordshire, there is potentially an alternative solution for us involving other providers, and we must now explore all options.

So what is the alternative?

Option 2, an alternate provider running the Alexandra site, was rejected by the Jan 14 ICRP report on the basis that it could have a detrimental effect on residual services provided by WAHT, particularly the specialised services. UHB were not involved in the ICRP process, and this opinion was based on the theoretical effect of Option 2 on WAHT. However, the conclusion depended on the assumption that WAHT would continue to exist as a separate Trust in the south of the county, and that WAHT would be able to provide Modified Option 1 in a clinically sustainable way.

Furthermore, since Jan 14 the Dalton Review and the Five Year Forward View/New Models of Care have been published. The arguments around Option 2 therefore no longer apply, and we must now look at other options including Dalton type models and the break-up of WAHT as a provider organisation, along with the role that could be played by UHB.

We know that the QE hospital in Birmingham is at the limit of its capacity, and will be seriously affected by acute patient flows from Redditch & Bromsgrove. We also know that patients in our CCG area look north rather than south, due not least to the much better public transport links to the QE. Over a quarter of the GP practices in our CCG actually lie within south Birmingham. It is sheer fantasy to assume that patient flows from Redditch & Bromsgrove would overwhelmingly go to WRH, a point that is picked up in the WMCS report along with concern about patients with protected characteristics or low incomes struggling to access hospital services.

The UHB management have previously offered to look at taking over the running of the Alexandra site but the range of services that UHB could provide has not been properly explored to date, for the reasons stated above. This situation cannot stand.

We remain concerned at the loss of Consultant-led Maternity from the Alexandra site. Centralisation of overnight paediatrics and Consultant-led Maternity is part of Modified Option 1, and we do accept that WAHT is struggling to safely maintain two obstetric units in Worcestershire.

However, there is a lack of maternity capacity in the wider geographical area which will result in a curtailment of patient choice, so we must have a wider review of capacity. We note that Birmingham Women’s Hospital has plans via a £70m project to expand its capacity from 8100 to 9200 by 2017/18. We believe that the possibility of BWH taking over the facilities at the Alexandra site should be explored – this could provide much needed maternity capacity to the whole West Midlands area.

Next steps

This process has been trying to come up with a solution that maintains WAHT as the sole acute provider for Worcestershire. The publication of the WMCS report confirms that after almost 4 years of trying, we do not have a clinically sustainable model to achieve this aim. Furthermore, WAHT’s financial position is unsustainable. Enough is enough, it is time to carry out an urgent wider review of all options, irrespective of provider, and without the precondition that WAHT must continue as a provider organisation.

Urgent action is required, because WAHT is struggling to maintain existing services, and they are advising us of a potential need to centralise emergency surgery in 4 weeks and maternity/emergency gynaecology within months via on safety grounds. Once gone the domino effect will begin at the Alex, and moving more services to WRH, an overcrowded and poorly performing site, will in our view increase risk rather than resolve it.

The WMCS report warns that centralisation of individual services on ‘emergency’ grounds must be avoided if at all possible as it is highly undesirable for any changes to be made outside of a strategic plan.

We are organising an urgent Extraordinary Governing Body meeting and will be asking Governing Body to support the following as our official policies:

1) We revisit all emergency centralisations of service and ensure all mitigating actions have been taken

2) That we insist on an urgent review taking into account the wider health economy and a full work-up of alternative provider solutions

3) These options will include models involving the break-up of WAHT and Dalton-type models involving UHB

4) A wider review of maternity capacity in the West Midlands including the possible role of BWH at the Alex site

5) A repositioning of our CCG as a north-facing organisation and a reappraisal of our historical ties with South Worcestershire, including shared funding mechanisms

We have asked for an urgent meeting with our local MPs to discuss the above and to ask for their help to enable us to achieve the best possible outcome for the Alexandra and acute hospital services for our patients.

If you have any questions or suggestions please get in touch with Jonathan or any of the Governing Body GPs to discuss further.

Dr Jonathan Wells

Chair of FoAHSW Clinical Subcommittee

Chair/Clinical Lead, Redditch & Bromsgrove CCG

GP Partner, Hillview Medical Centre, Redditch

Dr Marion Radcliffe

Chair of FoAHSW Emergency Task & Finish Group

Governing Body Member and Urgent Care Lead GP, Redditch & Bromsgrove CCG

GP Partner, Davenal House Surgery, Bromsgrove

Dr Richard Davies

Assistant Clinical Chair, Redditch & Bromsgrove CCG

GP Partner, The Ridgeway Surgery, Astwood Bank