Introduction
This is the response to the Surrey and Sussex Strategic Health Authority document “Creating an NHS fit for the future” presented by Jeremy Hunt MP and Anne Milton MP on behalf of the Cross Community Group from the Guildford and Waverley Primary Care Trust area.
The Group consists of representatives from all geographical parts of the area, all political parties, all tiers of local government, GPs, clinicians and consultants, staff representatives, and the voluntary sector. The aim of the Cross Community Group is to campaign on behalf of local people for access to appropriate local community, acute and rehabilitation hospitals services.
We welcome the opportunity to comment on this paper and hope that the Surrey and Sussex Strategic Health Authority will consider the strength of support and feeling contained within our response. We also look forward to an open and honest dialogue throughout the rest of this process.
Executive Summary
We have a number of concerns related to the document. These have been formulated during discussions with community groups, residents, GPs, consultants, nurses, voluntary organisations and local government representatives and focus on five main areas. Our key areas of concern are as follows:
- There is a fundamental problem with healthcare funding in Surrey. This has prompted the Strategic Health Authority to look at ways of saving in excess of £100 million per year.
- These savings will have a detrimental effect on healthcare provision in the county as it seems likely that the savings will be made by changing service provision available at the RoyalSurreyCountyHospital.
- We agree with the emphasis in the document placed on care in the community closer to people’s homes. However, this contrasts starkly with GWPCT’s decision to close MilfordHospital and the beds and day hospital at Cranleigh.
- The Strategic Health Authority have not considered the geography of the local area and have had no regard for the demographic make up of the local population. RSCH is the local hospital for a population in excess of 80,000.
- The document makes no attempt to provide a joined up approach to healthcare provision as it makes little or no reference to social services.
This document highlights each of these areas in more detail below.
Attached separately as an Annex to this document are a number of comments from members of the public made at our public meeting of 13 July 2006. These are non-attributable but represent genuine feelings and concerns that were voiced at the meeting. We feel that these add weight to our arguments and demonstrate the strength of feelings that run across the community on the issues raised within the discussion paper.
General Concerns
The Cross Community Campaign Group believe that the proposed restructuring of healthcare services in Surrey, as set out in “Creating an NHS fit for the future”, is largely based on the need for the Surrey and Sussex Strategic Health Authority to save money. If this is indeed the case then the Surrey and Sussex Strategic Health Authority need to be honest and upfront about this and consider a wide variety of potential cost saving measures. If these changes are a genuine attempt to improve services then changes that both cost and save money need to be considered.
The community feels let down by previous consultations on healthcare provision and there is a great deal of cynicism regarding any the whole consultation process. We are willing to work together with Surrey and Sussex Strategic Health Authority but only if there is a genuine desire to listen to our concerns and this is not simply a ‘box ticking exercise’. We remain dismayed by the cavalier attitude that has been shown to the wishes of the community regarding community hospitals.
Financial Issues
If insufficient money is coming into the region we would ask the health authority to join us in lobbying for increased funding from central Government.
The group fully accept that the majority of the funding problems in the Surrey and Sussex Strategic Health Authority area are caused by an inherent bias in the Government’s funding formula that determines the level of funds allocated to each health trust. We would draw attention to written evidence given to the House of Commons Health Select Committee’s inquiry into NHS deficits by Professor Sheena Asthana and Dr Alex Gibson that identified a “systematic bias in health funding against rural areas”[1] such as Surrey. They argued against the Government proposition that deficits were largely due to poor financial management or poor organisation of services as if this were the case then it would be likely that deficits were distributed evenly across the country. Professor Asthana and Dr Gibson point out that only 4 of the 60 PCTs in the most deprived quintile ended 2004-05 in deficit (6.7%), compared with 36 out of the 60 PCTs in the most affluent quintile (60%)[2]. Because of this distribution they argue that poor financial or clinical management is unlikely to be an explanation for any financial difficulties.
This evidence goes on to demonstrate that 17 of the 25 (68%) trusts that were in the least deprived and most rural quintiles were in deficit at the end of 2004-05, compared to only 3% (1 of 34) of the PCTs serving populations in the most deprived and most urban quintiles.
Responsibility for this pattern of funding lies with the weighted capitation formula, which is the main element of the resource allocation model. The formula is based upon the size of a PCT’s population, weighted according to various factors such as age, geographic differences in the costs of providing services, and per capita differences in health needs. While this may appear to be a rational means of distributing funds, there are a number of problems with the system. The most critical problem is the insufficient weighting given to demand for healthcare based on past and projected utilisation, which is further distorted by the exaggerated weighting that the formula places on measurements of additional health needs – above all, social deprivation.
At present, the defects in the formula have produced a postcode lottery. Being unhealthy and poor in many areas traditionally seen as ‘well-off’ or rural will often mean that you are more likely to encounter problems accessing the healthcare you need than would be in the same circumstances in an urban deprived area. Asthana and Gibson conclude that the funding formula “introduces a systematic bias in favour of deprived and urban areas and against affluent and rural areas because of the way in which it assesses ‘need’ for health care”[3]. We would point the Strategic Health Authority to other research supporting Asthana et al.
The group welcomes the emphasis within this discussion paper on moving healthcare services closer to the community. However, it should be pointed out that in order to provide care outside acute hospitals there needs to be considerable financial investment and it is not clear that such money is available. We also believer that it is by no means certain that any longer term savings will be made across the local healthcare economy as providing care in people’s homes can be expensive. For example, following a stroke a physiotherapist, speech therapist, occupational therapist, district nurse and home care support would all have to journey to a patient’s home. The Surrey and Sussex Strategic Health Authority appears to believe that savings can be made this way but we would assert that these savings will result only from shifting costs from the NHS to Social Services.
Acute Healthcare
“Creating an NHS fit for the future” makes it clear that the Surrey and Sussex Strategic Health Authority will be changing acute services in order to make substantial savings. The paper clearly states that the proposals “will reduce the size and number of hospitals”[4] and that in Surrey “we may well need fewer acute hospital buildings”[5]. We believe from our discussions with a number of people involved in the decision making process, that these savings may well be made by cutting healthcare services available at the Royal Surrey County Hospital (RSCH).
These services will have to be provided elsewhere - put simply any reduction in services at RSCH will result in the people of Guildford and Waverley having to travel further for the healthcare they need. A cut in A&E services would mean that residents in Haslemere would have to travel upwards of an hour by ambulance to get to the nearest Accident and Emergency hospital at Portsmouth. This would be an unacceptable situation. Any reduction in services will create longer travelling times and so cause increased suffering and pressure on the already fragile health of patients, increase congestion and cause financial hardship to some.
This analysis is supported by clinicians who have strongly voiced their concerns regarding any potential closure or downgrading of A&E services at RSCH. We have received representations from a consultant at RSCH who stated that without the RSCH there would be poor coverage for the A3 and no A&E between the M25 and Portsmouth and Worthing. We have listened to many warnings from clinicians that not only will patient care suffer as a result of any closure to acute services but lives would be put at risk.
The closure of any accident and emergency services at RSCH would have a damaging effect on the health of all residents. Increased ambulance journeys would put lives in jeopardy as some clinicians have pointed out that potential travel times of over an hour would be fatal for large numbers of patients. With the A3 and large numbers of both schools and geriatric facilities in the region the A&E services are already overstretched – any reduction would have dire consequences.
We would therefore call into question whether the Surrey and Sussex Strategic Health Authority has considered the full implications of what it appears to be suggesting. Our concern is that services provided at RSCH will be reduced but no alternatives would be available except at a hospital further away. Any community alternative will be slow to develop and people’s health will be put at risk.
We also have a number of concerns regarding the proposed creation of emergency centres[6]. These centres do not appear to have been fully costed or worked out with regard to the mix of staff that would be required. Indeed it would appear that if these were run in parallel with A&Es or other local hospitals then they could lead to an increase in healthcare costs in the area. We understand that respected opinion is divided on the viability, clinical effectiveness and cost saving of these centres.
A number of residents and clinicians have also pointed out that RSCH’s overall clinical excellence would suffer if the A&E department were to be downsized. RSHC currently enjoys top class consultants and other medical staff but there are fears that without A&E services these skilled staff, academics and researchers will simply not be attracted to the area. One consultant pointed out at our public meeting of 13 July that if you take away A&E from District General Hospitals then you don’t have a DistrictGeneralHospital as we know it. Many other hospital services are dependent on accident and emergency facilities and without them paediatrics, obstetrics and maternity departments would all be under threat. We urge the Strategic Health Authority to consider the wide-ranging impact that such closures would have on our community.
As is apparent from our comments above there has been considerable concern expressed across Guildford and Waverley about the rumour that accident and emergency services at RSCH will be ‘downgraded’ or closed completely. Our concerns are supported by GPs, hospital consultants, nurses and all levels of staff in the clinical and academic fields. In summary any downgrading of A&E will have significant consequences on the overall services provided at RSCH. Furthermore once an A&E is downgraded there is good evidence from elsewhere across the health service to suggest that other services fall in a domino fashion; research opportunities disappear, doctors’ training is put under threat and acute services are scrapped by stealth. We would stress to the Surrey and Sussex Strategic Health Authority that any changes to the acute services on offer in Guildford, or indeed anywhere within Surrey, would have a significant impact on other service provision in the county.
Community Healthcare
One of the key concepts expressed throughout “Creating an NHS fit for the future” is that more healthcare services should be provided as day cases, in patients’ communities and in their own homes.
This is a laudable move and consistent with Government rhetoric expressed in publications such as “A stronger local voice: A framework for creating a stronger local voice in the development of health and social care services”[7] and the health White Paper, “Our Health, Our Care, Our Say: a new direction for community services”[8]. However, following the recent decision to close beds and the day hospital at Cranleigh, the day hospital at Haslemere and MilfordHospital by Guildford and Waverley Primary Care Trust (GWPCT) we would question the actual commitment to such developments.
“Creating an NHS fit for the future” makes a clear case for the expansion of services provided by local hospitals such as those at Haslemere, Milford and Cranleigh. HaslemereHospital fills a huge gap in health care in the area and beds are essential for those not needing acute care at some other distant establishment. This hospital is unique in having a brand new Minor Injuries Unit with superior diagnostic facilities in terms of X-ray and ultrasound.
MilfordHospital is the second newest hospital in the PCT remit after Farnham. It was redesigned 20 years ago specifically for the rehabilitation of the elderly with complex needs and is located exactly central to the population centres of Godalming, Guildford, Cranleigh and Haslemere. CranleighHospital was a community hospital with 14 step down beds, a small day hospital, a monthly consultant led outpatient clinic and physiotherapy services. All of these play a vital role in the healthcare of the local region. There is also an ambitious plan to rebuild CranleighHospital with well in excess of £1 million raised by local people. Detailed planning permission has been granted and land donated and the project is ready to go, but only if there is some certainty in the local health economy.
This emphasis on the role of community hospitals will be even more significant if the RSCH were to be closed or downgraded. The recent closures and downgrading of community facilities within the Surrey area is weighty evidence against the warm words of the document regarding outpatient appointments, minor and day case surgery, GP treatments and specialist nurse treatments being “provided in the community[9]” and we urge the Surrey and Sussex Health Authority to fully utilise their potential.
The Local Area
We also feel that the demographic factors of the region are not being taken into consideration by the Surrey and Sussex Strategic Health Authority. Surrey contains a large elderly population that is set to only get bigger. It has been widely suggested that by 2050 there would be a 250% increase in over 85s in Surrey alone. Such a population obviously makes more frequent use of a considerable range of healthcare services than one with a lower proportion of elderly residents and as such we would again argue against a reduction in any healthcare services, particularly specialist services for the elderly such as those at Milford, or of Accident and Emergency services such as those at the Royal Surrey in Guildford. It also wrong to point to Surrey as a largely wealthy area when there are significant pockets of deprivation and many of the elderly residents mentioned are not wealthy at all.
In the future, the South of England will face increased and considerable infrastructure pressures as Government housing targets for the region are imposed. These would potentially see an additional 578,000 new homes across the region by 2026. Increased investment in vital infrastructure such as healthcare is required to cope with such demand. This situation cannot be reconciled with a cost saving exercise such as that proposed by “Creating an NHS fit for the future” that will possibly see a reduction in services.
The specific geographic and demographic factors within the health authority area make any reduction in healthcare services illogical. We would urge the Surrey and Sussex Strategic Health Authority to fully take into account these issues when presenting any future proposals.
Partnership Approach
We are disappointed that in producing this discussion document the Surrey and Sussex Strategic Health Authority has not shown leadership over the level of partnership working that is required for any successful changes in healthcare delivery in the region. Leadership should have been demonstrated by producing a joint document with social services and also by demonstrating a willingness to utilise, inform and engage with voluntary and community organisations.
Any community based delivery of healthcare services that focuses on treating as many people as possible within their own homes must be proposed in a fully joined up manner with the social services. It is not enough for the health authority to simply discharge patients into the community without thought or plans for their continued care and rehabilitation. It is vital that resources are invested in services outside hospitals and this cannot be achieved without significant input from other service providers.
Attention must also be paid to services that provide access to healthcare. Transport services in the county are limited and have a significant impact of the ability of residents to access the services they need. It is vital that these services are also taken into account in any potential reconfiguration of the location of health services and facilities.
The Strategic Health Authority must also work in partnership with its only clinicians, doctors, nurses, consultants and other staff members. A significant number of staff have voiced their concerns regarding any potential changes to acute service provision and their medical excellence and knowledge should not be treated lightly. If medical opinion states that lives would be put at risk what evidence does the Strategic Health Authority have to dispute this assertion? Indeed, how will the SHA manage a service when the people working in it and delivering care have no respect or support for the changes proposed?
Conclusion
The Cross Community Campaign Group from the Guildford and Waverley Primary Care Trust believe that “Creating and NHS fit for the future” leaves more questioned unanswered than it resolves. We are dismayed by the strong suggestion within the document that acute services in the region will face cut-backs and believe that the Surrey and Sussex Strategic Health Authority have not fully considered the relevant medical opinions or the overall consequences of such a move.
Although we know that the financial pressures faced by the SHA are significant, we would urge the Surrey and Sussex Strategic Health Authority to lobby the Government for further funding.
Finally, the Cross Community Group hope that as the consultation process continues Surrey and Sussex Strategic Health Authority fully take into account the significant and well informed opinions of our members. We will be the end users of any newly reconfigured healthcare services and as such deserve a major say in their development.