Anaesthetists’ Response

26 November 2012

Matthew Kershaw
Trust Special Administrator (TSA)
for South London Healthcare NHS Trust (SLHT)

We, the 23 consultant medical staff of the Department of Anaesthesia and Pain Management at University Hospital Lewisham (UHL), write to protest at the proposals contained in your draft report on the re-organisation of care in South London.  As anaesthetists are involved in over 60% of the income generating activities of hospitals, we are perhaps uniquely placed to give an over-view of your proposals
(Audit Commission Report http://www.audit-commission.gov.uk/subwebs/publications/studies/studyPDF/1712.pdf).

Our objections are based on the illegality of the process, the clinical and financial risk to health care provision for patients of Lewisham, and the adverse impact on teaching and training of health care professionals.
We note that your report is flawed on a number of counts:
1)      Process.  The proposals constitute a back-door approach to reconfiguration of healthcare in South East London, which contravenes the TSA terms of appointment (Statutory Guidance to Trust Special Administrators (TSA). https://www.wp.dh.gov.uk/ publications/files/2012/07/ statutory-guidance-trust-special-administrators.pdf ). The process and its time frame did not allow “due diligence” to be undertaken by Lewisham Healthcare NHS Trust (LHT) in the proposed merger with Queen Elizabeth Hospital, Woolwich (QEW). A “merger” of two hospitals suggests a fair distribution of assets and liabilities: but the report recommends the loss of over half the footprint of the UHL site, with closure of its A&E, ITU, medical beds, and downgrading of its Obstetric unit. This is not a “merger”.

2)      Inequity and Financial risk. The proposals are based on penalising LHT, a separate successful NHS Trust, with the huge PFI debt burden of another unrelated institution (SLHT). Our debts are manageable. The magnitude of the PFI debts of a combined LHT-QEH organisation are, by contrast, sufficient to cripple its delivery of clinical care (Appendix 1). Your report therefore suggests a PFI support schedule of  £12.1m – £13.5m per year until 2019-20 (page 59), but even this support will meet less than a third of the debt burden; and beyond 2020, there is a combined debt (for LHT and QEH) of some £700 million payable over the subsequent 20 years. Why should the children of current Lewisham residents be punished for the financial prudence of their local health care providers by being burdened with the debts of a failed neighbouring institution?

3)      A&E care. The closure of the A&E department at UHL would seriously disadvantage local residents and would impose a huge burden on neighbouring hospitals, which already struggle to meet their clinical targets. The suggestion that changes in care provision will reduce the A&E caseload in SE London is based on further speculation, and contrasts with the fact of increasing numbers of patients waiting in London Ambulances before being seen in London’s A&E departments, as reported this week by the BBC. The expansion of UHL’s A&E and Urgent Care Centre was based on clinical need and funded without PFI – yet the TSA’s proposals mean that Lewisham residents are to be prevented from benefiting from local investment in healthcare.

4)      Obstetrics. The downgrading of the Obstetric Unit at UHL would require transfer of care of large numbers of “high risk” mothers to adjacent hospitals which are already struggling to cope with their own clinical loads. This is unsound clinical practice.

5)      Surgical volumes and unsound clinical “evidence”. The proposed Lewisham Elective Surgical Site centre (which should perhaps be called “LESS”) with up to 44,000 cases per annum by 2015/16 assumes a referral pattern which has little basis in reality. As surrounding hospitals are to retain their day surgical centres, they are likely to keep their minor and intermediate cases, which will stay “local”. Neither will complex major cases be referred, as these would require ITU care, which you plan not to have at the LESS. This leaves a rather uncertain number of “simple” major cases to be done at LESS – presumably only if this can be achieved at less cost. Even “simple” major cases will, on occasion, need ITU care. If there is no ITU on site safe clinicians will modify their case selection to allow only the simpler major cases to be done at LESS, narrowing the selection profile further. Since there is no guarantee that future commissioners will wish to refer cases to LESS, the actual numbers of suitable referral cases would appear to be very limited. In addition, the throughput proposed to achieve financial viability at LESS assumes the highest productivity in the region, with an average of approximately 1 case per hour of operating theatre time, twelve hours a day, six days a week: this is not clinically achievable, even in the best of units. (Our theatre efficiency is currently in the top quartile of similar sized hospitals, in the mid 80% efficiency, achieving approximately half that throughput per hour). The proposed level of LESS “efficiency” would prevent our current commitments to teaching and training, and would require “cherry picking” the healthiest patients for “straight forward” surgery, as currently happens when low-risk NHS patients without multiple co-morbidities are selected for operative care in private hospitals. It is not clear who would cater for those patients who do not conform to “profitable” economic categories.

6)      “High risk” surgical cases and Emergency Admissions. UHL has the theatre and ITU capacity to accept its fair share of emergencies and maintain a surgical throughput of major surgery (eg colorectal surgery, re-do joint replacements, surgery in high risk patients). It is extremely rare for major elective surgical cases at UHL to be cancelled due to lack of a level 2 or level 3 beds. By contrast, centralising all emergencies onto one site would risk repeated cancellation of elective major surgical cases, unless HDU and ITU facilities were significantly expanded at the “hot” site. Your report makes no provision for this.

7)      Training. It has been truly said that “past performance is the best predictor of future achievement”. At the time of the formation of SLHT, “A Picture of Health” suggested that the new SLHT would provide new teaching opportunities and raise the standards of training in that combined organisation. Unfortunately this did not happen (appendix 2). Imagine our concern then when your report fails to mention teaching and training. The annual report of the South West London Orthopaedic Centre (SWLEOC) perhaps explains why such an omission is made, as it does not provide postgraduate medical training (The EOC; Orthopaedic Excellence, Annual Report 2010 Available at: http://www.swleoc.nhs.uk/EOCAnnual-Report-2010.pdfopaedic Centre).

8)      Theatre Caseload and training. The proposed LESS centre is based on SWLEOC at Epsom, which uses a Private Medical Practice model. Although SWLEOC produces excellent clinical results, based on nurse pre-assessment and consultant delivered surgery and anaesthesia, with postoperative consultant intensivist care, it provides minimal postgraduate medical training – and is a much smaller unit than the proposed LESS. By contrast, we have a significant commitment to teaching and training as a University Teaching Hospital – for nurses, physiotherapists, medical students and doctors in training. Such teaching and training is part of our ethos and helps to raise the standards of the care we deliver to the residents of Lewisham, who themselves provide many unique opportunities for learning about conditions which are otherwise rarely found elsewhere. Any proposed alterations to clinical care in SE London must include detailed costed considerations of the training needs of the nursing, midwifery and medical workforce necessary to provide future care to Lewisham residents. Indeed locally trained staff are more likely to stay – as UHL has found, where the turnover of staff is less than in other comparable units.

9)      In conclusion, it is very much easier to destroy a good unit, than to build an equally good unit elsewhere. LHT has successfully grown and melded itself from the amalgamation of many local hospitals over the past 20 years. This has been achieved with the active cooperation and discussion of senior medical, nursing and management staff, in conjunction with local health care commissioners and general practitioners, who are familiar with the needs of our local population. Inadequately thought out, hasty decisions will create needless casualties among both Lewisham and Woolwich residents, and cannot be in their long term interests. Your report puts at risk the current safe and effective care at LHT in favour of a theoretical construct underpinned by unsafe predictions of financial income, uncertain future referral patterns, and unattainable levels of production-line surgery. We cannot support your proposals for Lewisham Hospital and its patients as they would put at risk the quality and quantity of care we currently provide.

10)     Finally, “Quality is much more difficult to handle than quantity, just as the exercise of judgement is a higher function than the ability to count and calculate.” EF Shumacher, from “Small is beautiful – a study of economics as if people mattered”, Sphere Books Ltd, 1974.

Consultant Anaesthetist, University Hospital Lewisham, on behalf of himself and his colleagues, Doctors:

[22 names]
Appendix 1. The cost of PFI.   X axis = financial year end, Y axis = annual unitary payments during the life of PFI in millions of pounds per annum for each hospital.
(based on HM Treasury page:  http://www.hm-treasury.gov.uk/ppp_pfi_stats.htm, and selected information from spread sheet  ”PFI Current projects list March 2012″)
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