Secrecy surrounds recent development of NHS plans in Leicestershire. Local NHS bosses keep developing new flawed plans without ever learning the lessons of the previous ones. Now campaigners complain NHS chiefs are refusing to publish a key document: perhaps this is because after two previous failures they know it cannot withstand public scrutiny.
Leicester, Leicestershire and Rutland (LLR)) has just one acute hospitals trust, University Hospitals of Leicester (UHL) on three sites: for many years there have been plans to reduce this to two, with the loss of acute beds and services at Leicester General Hospital.
Proposals for this, running alongside cutbacks in community hospital services – predate NHS England’s Five Year Forward View in 2014. By summer 2014 the optimistically-named LLR “Better Care Together” project (“a partnership of Health and Social Care”) had already published its Five Year Strategy, followed in December by a “Strategic Outline Case” . This insisted that:
“the path laid out in the five year strategy is the only way of achieving clinical and financial sustainability” (p9).
It took less than two years to prove this, and much of the document, wrong.
The SOC had bravely promised to produce a series of business cases, which would apparently involve working through plans “in granular detail”. None have yet appeared.
Most proposals other than the precise number of beds to close, were vague: key to the SOC was a “left shift,” to care delivered outside of hospitals: “a vision for the future in which the community model of care is transformed, with far more provision of care taking place outside hospital in primary, community and home care settings.” (p10)
There were neither concrete proposals nor the necessary investment to expand community and primary care services to take on the extra work. Nonetheless the SOC anticipated that these changes would lead to:
“the reduction of 427 beds at UHL [24% of the total of the trust’s 1773 day and overnight beds], and allow the organisation to achieve its vision of moving from 3 to 2 acute sites by 2018/19, a core strategic objective.” (p10)
The SOC’s almost incoherent “Bed reconfiguration summary” went further, and argued the need to reduce UHL bed provision by an even higher number:
“In total, actions need to be taken across LLR to remove 571 beds from UHL. This is made up of:
“462 beds related to UHL efficiency reductions and left shift of sub-acute patients …
“109 beds related to workstream efficiency reductions. Overall, this will mean that UHL’s bed base will reduce by 427 beds because some of this reduction is required to reduce anticipated activity growth over the five years of the plan.” (p70)
The assumptions underlying this massive, sustained reduction in acute bed numbers at a time of increasing demand for health care were in the realm of fantasy:
“UHL and LPT [Leicestershire Partnership Trust] have agreed that 250 beds worth of patients can be cared for outside of an acute setting. The 250 beds are broken down as follows:
“170 where patients can be treated by expanded community teams;
“80 “sub-acute” beds, where patients need to be treated in an existing community hospital bed, with enhanced home care support.” (p71)
However the same plan, on the same page, also proposed to cut 87 community hospital beds – reducing LPT from 660 beds to 573 (p71). The plan’s authors hoped patients could be looked after in their own homes, by miraculous means:
“Services will be expanded to enable patients to be cared for in their own homes (equivalent to 250 beds worth of current activity, 170 direct from the current UHL activity and 80 from the existing community hospital activity).” (p90, emphasis added).
The SOC was unrealistic from the outset. One problem was hugely inflated claims of a massive financial gap. According to SOC projections in 2014:
“The total gap between income and expenditure for the NHS element of the LHSCE [Leicestershire Health and Social Care Economy] in 2018/19 is £398m before any CIP/QIPP or other projects are modelled.” (p10)
With a gap that big it was impossible to propose plausible policies to deal with it.
Two years later, in 2016, in an even worse financial situation, NHS England called for Sustainability and Transformation Plans to be drawn up in 44 new “footprints” across England. The LLR footprint plan came up with more bizarre and unexplained statistics and assumptions. Despite claiming almost exactly the same spending gap as the SOC two years earlier, the STP outlined a plan to cut a much smaller number (243) acute beds (13%) from a claimed total of 1,940 (p5). This made no sense. Department of Health figures showed a very different total number of beds for that year – just 1,665 (including day care beds). Leicestershire by this measure already had 32 beds fewer than the STP was seeking to cut back to by 2020.
The STP still proposed at the same time to cut community beds by 16% (38). Yet there were no serious plans to establish or resource the “intensive community support” or “integrated teams” envisaged in the STP (p33).
It all seemed like wishful thinking. STP reductions for acute and community beds were significantly smaller than the 2014 proposals, but equally unrealistic.
The hopes that diverting large numbers of patients away from A&E and avoiding the need for hospital treatment and thereby allowing hospital beds to be closed have proved unfounded. The pressures on front line services have increased. Only once since the spring of 2017 has UHL even managed to see and treat 90% of A&E patients within 4 hours: most of the time performance has been below 75%, despite the openeng of a brand new A&E facility. Even during the relatively easy winter of 2018/19, waiting times remained abysmal.
Indeed far from being able to close beds and care for patients at home, UHL core acute bed numbers have remained largely unchanged since 2014, with a significant (90%) increase in day only beds: bed occupancy across the relatively mild 2018/19 winter and for most of the year was routinely above 90%, leaving no scope for bed reductions. Without the bed closures, the huge cash savings hoped for in the STP have not materialised either: the most recent financial report to the UHL trust board shows that it was £31m adrift from its optimistic 2018/19 aim of delivering a £29.9m deficit (which would have resulted in a £0.8m surplus after support payments). This failure resulted in the loss of “provider sustainability funding” – and an end of year situation £50.3m worse than planned.
One reason local services have remained largely intact has been the consistent challenge by local campaigners. The Campaign
Against NHS Privatisation, and newly formed Save Our NHS Leicestershire along with the Leicester Mercury Patients Panel have staged demonstrations, held public meetings, drafted responses, tabled Freedom of Information Act requests, submitted questions, lobbied and briefed local council bodies and MPs. A hard-hitting critique of the STP by local campaigner Sally Ruane was published by De Montfort University in 2017, and a successful intervention by campaigners later that year effectively derailed plans to move towards setting up an Accountable Care System with no consultation. In the summer of 2018 campaigners published an even more detailed renewed challenge to plans to relocate Intensive Care (ICU) beds out of Leicester General. The proposal had been pushed through with virtually zero scrutiny and no consultation back in 2015 on the grounds that it was urgent: but three years later it still had not been carried out.
The reasons for campaigners’ concern was that it represented a major first step in downgrading Leicester General, and that it would also disrupt three specialist services for an indefinite period. Vital technical details had not been made publicly available, and even after three years CCGs had still failed to consult the public.
We have already noted the variance between successive plans for bed cuts in acute and community hospital.
How many beds are there?
A campaigners’ Briefing Paper for local MP and shadow health secretary Jon Ashworth completed earlier in 2019, notes a new, even higher claimed figure for numbers of UHL beds: 2,045 beds if we believe a Trust response to an FOI request in May 2018, or 1,992 beds according to two trust executives in meetings six months later. Both of these figures are much higher than official NHS figures for UHL bed numbers, the most recent of which was 1,874 (including 216 day case beds).
Nor is there any consistency on claims for how many patients could be cared for out of hospital: “One UHL spokesman stated 15% of patients currently in UHL beds did not need to be there; another spokesman stated 30% of patients in UHL beds did not need to be there.”
Some of these questions might be answered if the Trust, who are seeking £367m to reconfigure their acute services, would only publish a pre-consultation business case (PCBC) which they said last November they were about to send to the NHS investment committee for consideration.
Campaigners have been led to believe the PCBC is a very substantial document (although on previous record, size does not equate to quality). But six months on, despite repeated requests to see and discuss it, it is still being determinedly kept under wraps, allegedly at the urging of NHS England.
More than five years of slipshod planning, secretive processes, evasions of consultation and inconsistent documents give local people in LLR no reason for confidence in the Better Care Together project or the team running it. The longer the PCBC is kept secret the less credibility NHS bosses have with their patients and public.
Campaigners are now calling on local politicians to step up and add their weight to the demand for transparency. Previous schemes drawn up without consultation have proven to be deeply flawed: the danger is that NHS trusts and commissioners are again headed down this same dead end.