With hospitals crumbling and in dire need of replacement in Watford and in Harlow, but trust deficits soaring, the arguments rumble on about the cost of any replacement and in the case of Watford, where the new main hospital for West Hertfordshire should be located.

The Sustainability and Transformation Plan for this rather awkward area comprising the whole of Hertfordshire with the bit of Essex that was seen as least viable, was almost the last one published in December 2016.

It is also the skimpiest of all 44 STPs, with just 32 pages, watermarked “Draft” throughout. Almost nothing was explained, and no details supplied, raising far more questions than answers.

Since then the only part of the STP to have visibly proceeded seems to be the employment of a Programme Management team, whose activity appears to be largely restricted to occasional publication of extremely vague newsletters.

Their few initiatives are small scale attempts to plug gaps or remedy deficiencies in existing services rather than bold innovations.

The main tangible proposals of the STP were for acute care to be cut back, with the implication that primary and community services and mental health might be expanded, although there have never been any details or commitments.

The proposed acute service reductions were very substantial: however the likelihood of achieving them was always open to doubt. The STP hoped to reduce admissions of frail patients by a very precise 11,231 [!] within 3 years and 24,451 in 5 years. They also wanted to cut admissions for Respiratory, CVD, Diabetes, Musculoskeletal and elective treatment, by a total of 16,000 in 3 years and 36,000 in 5 years.

In fact in the two years of figures since the STP was published the numbers of patients aged 75 and over have increased by 4,000: emergency admissions have also increased, and the total of admissions has gone up by 7.5%.

The plans also look to cut hundreds of thousands of outpatient appointments (186,000 in 3 years and 456,000 in 5 years). The STP does not discuss the service implications of such large reductions in admissions and bed days for the acute trusts, but does commit to right size’ the hospitals’ overall bed base” (p20).

The greatest pressure on beds is at Harlow’s Princess Alexandra, a small hospital built in the 1960s for a much smaller caseload and which ended winter 2017/18 with bed occupancy above 99%, and just 67% of A&E attenders treated or discharged within the target 4 hours.

According to the STP West Essex could wind up with either a patched up Princess Alexandra Hospital – or the promise of closure and its replacement with a new £450m hospital on a “new” site, which may or may not be close to PAH.

A Commons adjournment debate on PAH on June 5 2018 brought news from Health Minister Stephen Barclay that the STP bid for £500-£600 million to develop a new hospital and health campus on a greenfield site to replace the old hospital had been sent back to the trust as “unsustainable.”

It’s clear that any future capital allocation towards the new hospital will fall far short of the amounts requested for a replacement on similar or larger scale.

Meanwhile long-nurtured dreams of a massive redevelopment of a health campus to replace Watford General – for which the same STP apparently bid for another £600m of capital – were also brutally killed off.

With them perished the hopes of determined campaigners in Hemel Hempstead (which lost its A&E to Watford hospital 10 years ago) and other parts of the county for an alternative scheme: a new major hospital, in a more central and easily accessible location than the often congested and steeply angled Watford General site, which is right next door to the Vicarage Lane football ground.

Watford was selected as the main emergency hospital because at that time it was a very important 3-way marginal constituency: but it is the most inaccessible. It can take an hour or more by car from St Albans or Hemel Hempstead at 8am.  By bus it is far worse – taking one and a half hours most times.

The West Herts Hospital Trust was in special measures for a number of years and the latest CQC report from late 2018 found it still needing improvement. It is £52 million in the red. The only new build at Watford to cope with the 300 plus beds lost from Hemel was a temporary building for 120 patients – a glorified Portakabin-style structure which was said to have a life of 10 to 15 years and has had major problems since it was built.

Clearly they couldn’t cope so some standard Portakabins, two floors, with Portaloos were put on the carpark. A recent ‘6 facet survey’ obtained by campaigners through FoI reveals there is over £200m of maintenance needed.

In 2017 a Strategic Outline Case which estimated it would cost £1b to build a new A&E hospital with 650 beds on a clear site bit the dust. In 2019 that figure has fallen to £750m – but this still seems very steep in comparison with other new-builds, and unlikely to be achieved.

Campaigners for an alternative site for a new hospital have published evidence to the CCG to show that building the hospital on the Vicarage Road site would cost at least £220m more, take far longer and pose more risks.

In June 2018 ministers also rejected the proposal for a new, more central hospital. Instead they rubber-stamped the down-sized Strategic Outline Case for rebuilding the crumbling Watford General, in a marathon project that will not complete until 2030 at the earliest: but then last December Chancellor Philip Hammond announced no more deals would be signed under the Private Finance Initiative, throwing fresh doubt on how much money can be raised for the rebuild.

NHS Improvement now says the Trust can only have what amounts to its turnover of £350m.  On that basis they have dropped a new build hospital and are only looking at 25 to 40% new build at Watford.   

Meanwhile in West Essex, the Princess Alexandra Hospital seems to be in pole position to be one of the first trusts to use a new form of private financing to help fund a replacement hospital.

Underinvestment means that the current condition of the estate is extremely fragile. A survey conducted in 2018 highlighted that 45% of the hospital’s estate was rated as unacceptable or below for its quality and physical condition. Little investment has been possible since then.

The Trust is considering whether it can generate part of the funding for a new facility 3.5 miles away in east Harlow through a new “regional health infrastructure company” (RHIC). According to the Health Service Journal:

“RHICs have been proposed by Community Health Partnerships, a government subsidiary, as a way of raising private capital for NHS infrastructure projects in a new form of public-private partnership. … However, the Treasury has not yet approved the model.

What details do exist suggest something very similar to PF2, the revised form of PFI in which public capital is used to keep down the cost of borrowing. PAHT has proposed a “blended” finance model to replace its main hospital in Harlow, to be financed through a mixture of land sales, capital funding from the government, and private income.

Unlike the Watford redevelopment, it seems certain that the new Princess Alexandra Hospital will be on a greenfield site: and the latest plan is for a substantial increase in size from the current 405 beds to 424 acute beds plus others – with a total of 633 beds and “care spaces”. This would make it almost the same size as the proposed Watford rebuild – but at what appears to be 20% of the cost.

In other words this STP has carried on the way it began: with chronic deficits, crumbling hospitals, wishful thinking, overpaid management consultants and sums that just don’t add up.

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