Trust Special Administrator (TSA)
for South London Healthcare NHS Trust (SLHT)
As trainee GP doctors in Lewisham, we work both in the hospital and in the community, delivering care in a range of settings. This dual role gives us a unique insight into the delivery of healthcare in Lewisham. We deliver primary care in GP surgeries across the borough, but we have all worked in Lewisham Hospital, many of us in the A&E department.
We acknowledge that, as they stand, current structures in South East London are unsustainable. The role of the TSA was to offer a financially sustainable strategy for delivering healthcare in this area and we agree that this is an important goal. However, the delivery of healthcare is not simply a financial discipline. As the public enquiry into Stafford Hospital has made so clear, ill-considered management decisions mean that people die.
We have identified five key impacts, informed by our expert knowledge as clinicians, our experience in care settings across the borough, and our familiarity with Lewisham gained from living and working in the community. These are:
- Patient Safety
- Other Clinical Provision
- Training Future Doctors
- Integrated Care
- Long Term Prognosis
We want to ensure that the people of Lewisham receive excellent care, whether in a GP surgery, an elective care centre, or an A&E. We stand ready to work with the administrator to ensure that we find a solution which is both financially viable and promotes the health of Lewisham. These proposals meet neither of these criteria.
We would welcome the opportunity to engage further and provide evidence or advice to help develop a solution.
|Dr Nasreen Ahmed||Dr Liza Kirtchuk|
Impact: Patient Safety
Our most basic responsibility as clinicians is to ensure the safety of our patients. This duty does not stop at the door of the surgery or hospital. The proposals to reconfigure secondary care in Lewisham present a clear threat to the long-term safety of the people of Lewisham and South-East London and it is our clear clinical and professional responsibility to advise you of our concerns.
The loss of the A&E will mean patients and relatives will have to travel further to receive care. The administrator’s report notes that up to 80% of patients currently seen in Lewisham A&E could be managed at an urgent care department in Lewisham. This still leaves at least 1 in 5 patients requiring transfer elsewhere. Moving clinicians and patients between sites and services risks the loss of information and disjointed care.
The current transport infrastructure means it may take patients up to 90 minutes by public transport to reach these new proposed A&E sites. Presumably it is expected that acute cases will receive ‘blue light’ transfers to these sites. However, there is no mention for the increased use of the London Ambulance Service and where the resources will come from. Currently, patients with specific changes on their ECG are taken directly to the coronary care department at King’s College Hospital. There are strict protocols and training that enable paramedics to decide which patient goes to which centre. We are concerned that there has been no mention as to how this triage system will work for all patients in South East London needing urgent assessment. There is a risk that patients who need urgent treatment for basic but acute problems will be left waiting, deteriorating, due to lack of ambulance or clinicians for transfer, or as a result of bed shortages.
Similarly it seems that little thought has been given to how other hospitals will cope with this increased workload. There are proposals to shift more care into community led services but there are no details as to how this will occur or be funded. Theses services have not yet been designed or commissioned. Already, there are bed shortages and difficulties transferring patients who might need specialist opinion such as urology or paediatric surgery.
Impact: Other Clinical Provision
The loss of acute services will have a substantial impact on other clinical services available locally. Accident and Emergency services are not delivered in a vacuum but are vital for the safe and effective provision of other kinds of medical care which may initially appear unrelated.
In particular, we have significant concerns about the future of maternity services. In an area of significant deprivation, pregnant women often seek medical attention late into their pregnancy and often have other medical problems such as diabetes. The proposal of a ‘stand alone’ service raises safety concerns, particularly with the medical and social problems faced by many of our patients, contributing to complexity of care. Delivery of effective maternity care requires support from a wide range of specialties, including emergency medicine.
A similar impact is likely to be felt on other services
- General medicine
- Radiological services
- Intensive care
Removing provision of A&E reduces the ability for these services to operate safely and effectively. Having an “elective surgery centre” at Lewisham sounds unfeasible, with the huge investment required to build theatre space to accommodate this; that money could be spent improving already existing services or tailoring them to fit within the integrated care model. We are concerned about the lack of clarity of the plans, such as where postoperative complications might be managed.
We have serious concerns over how these proposals will affect vulnerable groups of patients such as the elderly and children. Safeguarding children works through the communication between general practice, community and social services and acute medical services. Children who are at risk of being abused may fall through the system if they present at the proposed larger A&E sites without the back up of the local community services.
Impact: Training Doctors
As doctors training for a career in General Practice, we are particularly concerned about is the impact this proposal will have on training, both immediately and in the long term. As part of our training, we work both in Lewisham hospital and in the community, providing us with a unique perspective of the healthcare needs and provisions in our area. Most of the doctors who trained in Lewisham have stayed to be GPs in this area, building on the knowledge we have gained from working in the acute setting to serve the people of Lewisham.
The proposal by the TSA suggests that by creating specialist emergency centres surgeons will have better access to surgical procedures and will therefore provide better care to patients. We feel that this is incorrect. By creating large centres there will be more doctors trying to gain operative experience on those cases. With a rota system required to provide service provision across the hospital, surgical trainees run the risk of losing out on valuable operative experience that would normally be the basis of their training in the first few years in district general hospitals.
The loss of acute services will mean fewer training posts for doctors to learn their vocation whilst caring for the population of Lewisham. This will not simply affect A&E doctors. Lack of exposure to emergency medicine makes it less probable that accrediting bodies such as Deaneries will support training posts in key specialties such as general medicine and surgery. It is unclear who will provide junior support for the elective surgical cases, from assisting in theatre to providing post operative care.
This not only reduces the number of doctors working in Lewisham who are familiar with the borough through their training – it will have a direct impact on the number of junior doctors actually working in Lewisham. Some trainees will be transferred to other hospitals, but it will inevitably lead to the loss of jobs and dilution of skill.
Impact: Integrated Care
One of the most welcome developments in healthcare over past decade has been the growing focus on integrated care, building a patient centred service in both primary and hospital services. Delivered effectively, this approach not only improves patient experience, but also actually cuts long term costs. However, to work effectively local clinicians must have access to the entire spectrum of care – from community based intervention to emergency critical care.
Clinicians in Lewisham have worked hard over the past few years in building a relationship between primary and secondary care to the serve the population, trying to tailor the services to the needs of this population. This relationship will be undermined by the loss of acute services. Without the feedback from emergency attendances and admissions, we will lose valuable insight into the needs of the people of Lewisham and ultimately this will lead to deterioration in the integrated care approach.
Through ongoing dialogue between the hospital and the CCG (Clinical Commissioning Group), we have been able to tailor services such as the diabetes service; huge improvements have been made to the care of patients in this area. It is likely that the tailoring of care to a particular population and the strength of working relationships between primary and secondary care will suffer as a result of these proposals.
This integrated method of providing care presents an alternative approach to saving money, whilst simultaneously improving the quality of care delivered to the people of Lewisham. It is with long-term, investment-focussed thinking that this can be achieved and represents the antithesis of the short sighted approach which has seen South London Healthcare find itself in administration.
Impact: Long Term Prognosis
The crisis at South London Healthcare was ultimately caused by short-term thinking, with little consideration being given to the long term revenue impact of major capital projects. This crisis cannot be solved by another short-term response which ignores the possible far reaching consequences.
According to the most recent ONS (Office of National Statistics) projections, the population of Lewisham will grow by 50,000 people over the next two decades. This is the equivalent of an entire commuter-belt town coming to the borough, before we even begin to consider the impact of similar population growth in South London’s other boroughs.
We noted earlier the adverse impact of such changes on other hospitals at current levels of demand. With population growth across South London this will only intensify. Just as we believe that it is manifestly wrong for the people of Lewisham to pay for poor management of another hospital, it cannot be right that patients across London will also receive poorer quality care.
Meeting the needs of such a population will require primary and secondary healthcare services, including provision of accident and emergency. This will demand significant additional investment in existing services, or the creation of new provision. In this context, the proposal to withdraw emergency healthcare services from Lewisham is both clinically and financially irresponsible. The fact that millions were recently invested in A&E services at Lewisham serves to further highlight the need to reconsider this proposal.