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Elective care

 UPDATE

  • On 28 November the Joint Health Overview and Scrutiny Committee of the 6 London Boroughs covered by OHSEL voted not to accept OHSEL’s recommendations for a two centre model for elective care because they had not included an option for an ‘enhanced status quo’ option which would ensure that Lewisham and Greenwich Trust would not be put in danger financially or operationally. OHSEL have been asked (again) to provide a worked out option.

  • The following day, at the Committee in Common meeting of 6 CCGs which had been expecting to approve the beginning of consultation on the two-centre model, came under a barrage of questions from Save Lewisham Hospital Campaign, Greenwich KONP and patient representatives, over its failure to include an enhanced status quo option. A representative of OHSEL was still maintaining at the meeting that it was ‘just a question of language’ but eventually Mark Easton, OHSEL Programme Director, agreed that a 3 centre option would be considered if the three Trusts provided such an option. 

SUMMARY OF OUR CONCERNS

Here is a summary of our concerns about Our Healthier South East London’s plans to put elective orthopaedic care into two units, which will very likely exclude Lewisham and Greenwich Trust.
This proposal could have negative impacts on Lewisham and Greenwich Hospital Trust, particularly Lewisham Hospital which undertakes the bulk of elective surgery (non trauma) and its ability to fully staff its orthopaedic and A&E services, on finances, and on training at Lewisham University Hospital. 

Proposal for centralised elective (planned) orthopaedic care centres

  • OHSEL’s flagship proposal is to centralise all elective orthopaedic surgery on to two elective orthopaedic centres (EOC), with their preference being Guys (Guys & St Thomas’) and Orpington (King’s). Lewisham & Greenwich NHS Trust would no longer do elective orthopaedic surgery in their hospitals;
  • Specialist centres for stroke, major trauma, heart attack and vascular emergencies have evidence for regional centres providing better outcomes
  • There is also evidence that protected elective operating systems provide better outcomes when linked to good joined-up pre- and post-operative multi-disciplinary teams.
  • There is no evidence that says standalone specialist centres would be better than for example, three centres one each in the three main trusts, with investment to provide better more ring-fenced elective pathways (protected from disruption by emergency work). This is the ‘enhanced status quo’ option. OHSEL has refused to work up this proposal and it has NOT been evaluated, and was not part of the option appraisal
  • Planned care (including orthopaedic surgery) has £36m savings badged against it. The elective centres are the only proposal worked up, and savings are clearly prioritised here – a worry when pre- and post-operative care involve staff-intensive input.
  • The Government has placed an embargo on central capital funding for NHS projects for three years 2015/16-2018/19. The capital funding required to provide the EOCs will be at least £10.2m and will have to be raised from the private finance market.
  • Lewisham and Greenwich residents will lose their local provision linked to local community networks directly.
  • We insist on seeing the ‘enhanced status quo’ option and that it is appraised fairly.

The document reproduced on the page below represents the views of local campaigners from the Save Lewisham Hospital campaign and Lambeth Keep Our NHS Public.

The paper reproduced on this page was prepared for the Joint Health Overview & Scrutiny Committee (JHOSC) which oversees health issues in the six boroughs of SE London. You can download the paper here.

We are not querying the search for improvements in elective care. However what we are querying is moving the work into 2 centres – one in an outer borough almost certainly the PRUH in Orpingron, owned by Kings, and one in an inner borough, almost certainly to be Guys Hospital.  
Please read our document below and be prepared to offer your views in the short OHSEL public consultation. 

Elective care

  • Elective care – or planned care – is non-emergency health care.
  • Planned care is one of the 6 main strands of the work undertaken by the OHSEL programme.
  • OHSEL’s work commenced December 2013 and work on elective orthopaedic surgery commenced Spring 2014.
  • OHSEL has settled on the consolidation of planned orthopaedic surgery in two centres rather than continuing to provide it across all the hospitals in SE London.
  • The cost of this is two-fold: capital expenditure is in the 10s of £millions. There is no capital funding available other than private finance. This is extremely costly for the next generation.
  • The Foundation Trusts are wealthier than Lewisham and Greenwich Trust and at an unfair advantage in raising capital.
  • In reaching this decision, OHSEL has failed so far to evaluate the very realistic option of investing to improve the current provision. After 2½ years of work on planned care, this omission is not acceptable.
  • The London Clinical Senate report strongly recommends that the enhanced status quo option be evaluated fully, and points to numerous concerns about the consequences of pursuing the two elective centres option, with relative lack of regard to the rest of the pathway, before and most importantly after surgery after discharge. See analysis of the Clinical Senate report on these points by a Lambeth KONP member. 
  • Enhancing the status quo could realistically raise standards to the required level (see Briggs Report) whilst avoiding both the financial risks and the risks of destabilisation of local health providers, whose integrated service and ‘business plan’ would be jeopardised.

 

OHSEL’s own clear hurdle criteria failed

We have major concerns about the elective care proposals. In our view they significantly fail to meet two of OHSEL’s own criteria (which, if not met, would theoretically rule out the option):

  • Firstly: that the proposals do not undermine the stability (financial or clinical) of local NHS providers.

“13. Organisational sustainability
The option maintains or improves all organisational positions. Any option which could destabilise the ongoing financial and organisational viability of the individual organisations without a compensating strategy will be ruled out.”

OHSEL document Planned Care: Elective Orthopaedic Centre, Draft Evaluation Criteria v7 point 13 page 6.

  • There is an undeniable risk to the providers where the centres are not based.
    • Tariff-based funding of the NHS leads to penalising of hospitals who lose activity to a specialist centre.
    • Staff recruitment will be affected if there is a loss of activity in essential surgical experience required for training and job satisfaction
  • Secondly: that there should be sound clinical and financial evidence supporting the proposed change. The soundness of the evidence must be in context: ie in comparison to the clinical and financial evidence of other options – notably the ‘enhanced status quo’.

There are other clinical consequences, both direct and indirect, of reconfiguring this high volume area of surgical activity away from the local hospitals, such as Lewisham and QE Woolwich.

  • Disruption to local care pathways already established around the district’s hospital, multidisciplinary teams including social services – the Clinical Senate states that insufficient attention has been given to this significant part of the pathway (pre- and post-surgery).
  • Impact on the training of staff (medical, nursing in particular) if high volume activity important to training is diverted from the local hospital teaching and training environment and trainees cannot easily leave that hospital to experience the surgery at the centres.

 

OHSEL has failed to evaluate the enhanced status quo option and this is not acceptable

The process has completely failed to seriously evaluate the most obvious option: that of building on the already good performance and outcomes in the SE London health economy  to enhance current provision. That option was highlighted repeatedly by the Clinical Senate Report and MUST be taken up (see appendix).

Why? Because current clinical performance is not far short of the Briggs national standards and London average, and relatively much more affordable investment in current services could attain those standards. At least that option must be fully evaluated.

OHSEL’s failure to evaluate the ‘status quo’ option to date necessarily means that the evaluation of site options for the proposed centres has been biased, incomplete and fatally flawed. OHSEL belatedly plans to cover this failing, but too late to correct a flawed process.

This consultation must be halted, the enhanced status quo option fully explored, and then the full set of options subjected to a new option appraisal.

Representatives from our campaigns have attended patient reference group meetings, Committee in Common meetings, have given evidence to the Clinical Senate Review meeting and a group of us met with OHSEL on 30 September 2016. These same points have been raised throughout this process.

 

ADDITIONAL  POINTS:
Is elective surgery really the clinical priority?

Given the relatively high performing current elective surgery services in SE London (not far short of the London average) this is simply not the priority given the financial and clinical risk, the disruption to current services and extra travel involved for patients.

Higher priorities include the emergency pathway, care of the elderly, primary care and mental health. This is where 10s of £millions should go rather than into private financing schemes to fund the elective centres.

The model is based on flawed activity data

The model has not included the large amount of added capacity required to meet the waiting list numbers, on top of activity data, which in itself is already 2-3 years out of date being based on 2013/14 data.

Improvements to care?
Clinical improvements, according to Briggs, are not just about actual times spent in hospital but about improving pre- and post-operative pathways. These are relatively ignored aspects of care, separate from the proposed new centres, but essential to the success of the pathway.

The London Clinical Senate review contains no fewer than 30 requests to OHSEL that it addresses these aspects of the pathway without which the proposals cannot be safely evaluated. (See Appendix Analysis of Advice on Proposal for elective orthopaedic care in South East London, London Clinical Senate Review June 2016)           

EQUALITIES IMPACT ASSESSMENT

The London Clinical Senate Review stated on five occasions that there had been insufficient attention to the impact on equalities:

Based on the evidence we saw, equalities issues have not been sufficiently explored in the case for change. These include general issues such as travel times and costs (and any socioeconomic impact for specific population groups), disease specific issues such as complex medical care, readmissions etc and patient population issues such as such as mental health, learning disabilities, vulnerable groups and age. There is limited information about any current inequalities in relation to elective orthopaedic care or the implications of future demographic changes, particularly at a borough level where there is likely to be greater variance than for south east London as a whole.’ See Appendix Analysis of Advice on Proposal for elective orthopaedic care in South East London, London Clinical Senate Review June 2016)

 

Dr Tony O’Sullivan
Olivia O’Sullivan
Save Lewisham Hospital Campaign

Wendy Horler
Lambeth Keep Our NHS Public