Despite the Long Term Plan, the drive to cut, downgrade and ‘centralise’ services continues
If we believe the promises made by the NHS Long Term Plan, published last month, then there is at least a truce if not an end to the war of attrition on hospital bed numbers that has been running for the last 25 years.
The Plan differs from many previous plans in setting out what appears to be a more sensible approach, recognising the need to reduce the level of pressure on front line beds and staff, with many acute hospitals running close to 100% occupied for weeks and months on end.
It says (page 9): “In the modelling underpinning this Long Term Plan we have … not locked-in an assumption that its increased investment in community and primary care will necessarily reduce the need for hospital beds.
“Instead, taking a prudent approach, we have provided for hospital funding as if trends over the past three years continue. But in practice we expect that if local areas implement the Long Term Plan effectively, they will benefit from a financial and hospital capacity ‘dividend’.”
This follows on NHS England’s “fifth test” that since April 2017 supposedly must be met before cutting back on bed provision:
“local NHS organisations will have to show that significant hospital bed closures subject to the current formal public consultation tests can meet one of three new conditions before NHS England will approve them to go ahead:
Demonstrate that sufficient alternative provision, such as increased GP or community services, is being put in place alongside or ahead of bed closures, and that the new workforce will be there to deliver it; and/or
Show that specific new treatments or therapies, such as new anti-coagulation drugs used to treat strokes, will reduce specific categories of admissions; or
Where a hospital has been using beds less efficiently than the national average, that it has a credible plan to improve performance without affecting patient care (for example in line with the Getting it Right First Time programme)”
This all sounds much more sensible and civilised than the previous rush to closures.
Unfortunately the LTPs’ apparent national change of line is sharply at variance with the continued drive in many areas to implement ill-conceived local plans for “centralising” emergency services and specialties – with little regard for the problems of access these plans create for communities living near the downgraded and downsized hospitals.
From Dorset to Sunderland, Somerset to Lincolnshire, from Kent to Chorley, in the East and West Midlands, in north and south London and in many other areas, a whole raft of plans to centralise services, many of them pre-dating the 44 controversial Sustainability and Transformation Plans (STPs) drawn up in 2016, are still being forced through in the teeth of local opposition.
Reductions in acute bed numbers and numbers of A&E departments were key to over 50% of published STPs in 2016; the Long Term Plan and the associated Operational Planning and Contracting document published before Christmas make proposals based on the STP areas, bringing these plans back into focus. They were not good or complete plans.
Derbyshire STP had the greatest level of explicit bed closures with plans to close 530 by 2020/21. Kent and Medway STP proposed to reduce 2,896 beds to 2,600 in 2020/21, based on optimistic assumptions about reduced activity, reduced length of stay in hospital, and sustainable levels of bed occupancy. Hampshire and the Isle of Wight aimed to cut 300 beds, Nottinghamshire 200 and Herefordshire and Worcestershire STP – covering two crisis-ridden acute hospitals with chronic capacity problems – wanted to close 202 community beds.
However Leicester, Leicestershire and Rutland STP, following on from a previous reconfiguration plan, has had to back away from its initial plan to close 243 acute beds because of a severe and obvious lack of capacity in the winter of 2017. Its current plan is under attack from campaigners for offering no increase in beds to meet rising demand.
Three years after the STPs were drawn up A&E downgrades to “urgent care centres” are still threatened or under way in various places including Shropshire, Lancashire, Dorset, North West and North East London, and Weston Super Mare, while similar plans have been forestalled by vigorous campaigns in North Devon and Mid and South Essex.
Many of these plans, which have generally been delayed rather than abandoned, rest on claims that medical staff shortages mean that only one hospital in the area can be properly staffed to deal with specialist cases and emergencies. However these staff shortages have in almost every case been worsened over years by the blight of uncertainty that Trust and CCG managers have created over the future of the hospital that is to be downgraded.
The conditions for staff, especially those who will have to transfer to more distant hospitals, are also ignored, despite the evidence across the NHS that relentless pressure generates stress and burn-out for doctors and other professional staff, undermining quality of care and leading to sickness absences, burn-out and new staff shortages.
Plans based on this approach also almost invariably fail to address the problem of ensuring there is sufficient capacity in the new system to accommodate the likely level of demand for care: many completely ignore the issue of distance and travel times, the non-existence or inadequacy of public transport, and the impact of longer journeys in delaying access and impeding relatives and visitors.
Some try to bamboozle local people with largely spurious “research” on travel times by management consultants who are clearly ignorant of local conditions, and cite figures researched online from miles away that ignore local geography, traffic congestion, delays in making connections and the gaps in public transport provision especially to rural areas out of normal working hours: none seem willing to admit the costs of taxi fares for patients and visitors for whom no private or public transport option exists.
To make matters worse, there is a chronic shortage of capital to finance any expansion of redevelopment of the new “centres” to accommodate the increased caseload.
Indeed even the old, costly, standby of funding through the Private Finance Initiative has been halted since Chancellor Philip Hammond’s announcement last November (amid growing evidence of the cost to the taxpayer of the collapse of PFI giant Carillion last year) that the government would not sign off any more new schemes. Other ways of delivering private funding are being explored instead, but not yet being rolled out in the NHS
‘Centralisation of services’ without capital investment and the development of alternative services to support patients locally is just another way of describing cuts. And despite the claims that such plans are “clinically led” and aimed at improving the quality of services the reality is that most are financially driven, and seeking so-called efficiency savings regardless of the consequences for unfortunate local communities whose services are to be sacrificed.
Recent statements by the Royal College of Emergency Medicine reported elsewhere in this issue of The Lowdown highlight the need to question claims that plans are “clinically led” or led by “doctors” since opinions can be quite different depending upon which doctor you ask, and in any case their views can be misrepresented.
For example the plans for reconfiguration of services in Calderdale and Huddersfield claimed endorsement from the Yorkshire and Humber Clinical Senate, while in fact the Senate report was posing sharp questions about the viability of the proposal and challenging the lack of any detail or proper engagement with local GPs.
Another line of argument dating back to the 1990s is to argue that demand for hospital care can somehow be miraculously reduced by GPs taking on more responsibility, or by expansion of community-based and other “out of hospital” services. This is made less plausible not only by the quite obvious year by year increases in emergency and elective hospital caseload ever since the 1990s, but also by the severe and growing problem of recruiting and retaining GPs. Three years of international recruitment have yielded just 34 GPs.
More recently the notion of “integration” – vaguely defined and ambiguous on whether it means integration of NHS services or integration with (largely privatised and under-resourced) social care – has been thrown in to the mix as a magical means to reduce demand for hospital beds, length of stay and costs.
Of course it would be foolish to denounce any serious efforts to integrate NHS services. Any steps to reverse the disintegration and fragmentation of services through contracts and outsourcing (which were massively increased by Andrew Lansley’s 2012 Health and Social Care Act) would obviously be welcome.
The National Audit Office (NAO) in 2017 cast doubt on savings plans associated with health and social care integration and its likelihood to reduce hospital activity, putting its conclusion bluntly: “There is no compelling evidence to show that integration in England leads to sustainable financial savings or reduced hospital activity” (pp7-8).
Similar findings from the King’s Fund, the Health Foundation and most recently the Nuffield Trust all underline the same point: integration may well, if done correctly and with adequate resources improve patient care, but it is unlikely to save money or even reduce the need for hospital treatment where improved services begin to address previously unrecognised needs.
So before we get too excited by this and other promises in the Long Term Plan we need to take a good hard look at the situation on the ground, and the policies actually in play. Where there is a contradiction, we need to use this to strengthen the hand of those fighting to defend local access and adequate provision of services against ill-judged and short-sighted attempts to make savings.