Kidderminster s health: monitoring and evaluating the reconfiguration of the NHS in Worcestershire

Transcription

1 Health Services Management Centre Kidderminster s health: monitoring and evaluating the reconfiguration of the NHS in Worcestershire James Raftery Marguerite Harris 2005

2 Published by: Health Services Management Centre, University of Birmingham, Park House, 40 Edgbaston Park Road, Birmingham B15 2RT. University of Birmingham 2005 First Published 2005 All rights reserved. No part of this publication may be reproduced, stored in a retrieval system or transmitted, in any form or by any other means, electronic or mechanical, photocopying, recording and/or otherwise without the prior written permission of the publishers. This book may not be lent, resold, hired out or otherwise disposed of by way of trade in any form, binding or cover than that in which it is published. ISBN

3 Contents Page No. Chairman s foreward 5 Acknowledgements 9 Executive Summary 11 Chapter 1 Background and research methods 13 Chapter 2 The context: reconfiguring the NHS in Worcestershire 25 Chapter 3 The influence of the Private Finance Initiative 35 Chapter 4 Changes in the use of the NHS by Kidderminster residents 39 and of Kidderminster hospital Chapter 5 Hospital beds and emergency services in Worcestershire 49 Chapter 6 Waiting lists and times 59 Chapter 7 Complaints, patient surveys and national performance indicators 65 Chapter 8 Public health and the socio-economic context 69 Chapter 9 Stakeholder interviews 73 Chapter 10 Surveys of medical staff in Worcestershire: and 2003 Chapter 11 Discussion and conclusions 85 Glossary of terms 91 Appendices 1 The research protocol 93 2 Kidderminster chronology of key events 99 3 Worcestershire GP and Consultant Questionnaire 105 Results 4 Free comment in questionnaires Worcestershire GPs and Consultants 117 3

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5 Chairman's foreword CHART, initially called Health Watch, began its work almost five years ago, charged with the task of commissioning an independent academic study of the impact of the hospital reconfiguration plan on those served by Kidderminster District & General Hospital, - a task that the authorities had declined a proposal to undertake. The initial intention was to include both the Worcestershire Health Authority and the Social Services Department in the body managing the research together with the key groups and organisations relevant to the study. But, sadly, the Health Authority and its membership decided not to cooperate and the Social Services felt obliged to follow suit. Nevertheless, after wide consultation, CHART was set up with a carefully structured membership, and established as an approved Charity and Registered Company. Its aim was to replace conflicting views and opinions with reliable facts for the benefit of the future service. This study was inspired by those at the University of York whose earlier work 1 both questioned the clinical and financial benefits of re-configuration and clearly underlined the need to evaluate such changes. Subsequently, in tackling this novel exercise, we have had valuable encouragement and guidance from many academic centres and authorities right across the U.K. to whom we are much indebted. National competition led to the appointment of a research team from the Health Services Management Centre, University of Birmingham led by Professor James Raftery. They are to be congratulated on completing their three year task so successfully, undeterred by the adverse political climate. They have endured a continuing cascade of changes throughout the National Health-Service and medical practice and have experienced a lack of cooperation from some service components, often from those who should have been keen to participate and learn of their long and short comings from an independent academic scrutiny. 1 Concentration and Choice in the Provision of Hospital Services CRD Report 8. Sheldon T et al. University of York

6 A key and much appreciated figure in the completion of the study has been Marguerite Harris appointed as the Research Fellow for this project bringing with her so much expertise, ability and commitment. The Research Team s special expertise in extracting and interpreting NHS data has proved invaluable in evaluating the clinical aspect of the reconfiguration changes. The report, now before us, reassuringly, from the patient s point of view, indicates that while there have been some significant changes in timing and access to care the overall uptake of acute (hospital) services has not varied very significantly, tending, as it has increasingly, to mirror the fortunes of the NHS generally. While CHART had also intended to assess the personal and social consequences of the relocation of services on patients and families, the absence of input from Social Services sources and others proved to be a major handicap. Sadly efforts to acquire this information from NHS patient questionnaires and studies have been unsuccessful for various reasons. Therefore CHART decided to embark on a parallel study, to be undertaken by Mori, to this end within the time-frame of the principal project. Most unfortunately, despite well laid plans and very good local support, it did not prove possible to establish adequate funding which was most disappointing. CHART will be producing its third, and more detailed report setting out its activities, experiences and conclusions - both as an account of its work to those who have given support and encouragement, have been interviewed, completed questionnaires etc. and, needless to say, those who have generously funded the academic research programme, most notably the League of Friends. In addition there may well be others who wish to follow the example of this landmark exercise, where a community has implemented an academic appraisal of NHS services, hopefully they will find our study and experiences useful as a reference. CHART s report is due to be published in June, and will be available on 6

7 None of CHART s work would have been possible without the freely given and continuing commitment and support of all of the Council Members, its officers and secretarial staff; coupled with the invaluable support of so many others who have been committed with fundraising activities to support the work of CHART itself. We, as the community, are greatly indebted to them all. John Ball Chairman Community Healthcare Audit & Research Trust 7

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9 Acknowledgements Assistance and advice are gratefully acknowledged from Professor Peter Spurgeon, Dr Louise Locock, Dr Hugh McLeod and Dr Mike Harley, all at HSMC at the relevant times. Thanks also to Professor Chris Ham of HSMC for comments on an earlier draft. As always, errors remain the responsibility of the authors. 9

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11 Executive Summary This study, commissioned by CHART, a freestanding independent Kidderminster charity, focused on the health community formerly served by Kidderminster hospital. The study aimed to: a) review the clinical safety, economic and social impact of the NHS reconfiguration in Kidderminster, and b) assess the impact on perceptions of health professionals, patients and the population of Kidderminster and surrounding areas. The key issue of clinical safety was to be explored by two methods: monitoring changes in the levels of use of health services by the relevant local populations, and exploring in interviews and surveys the effects of any reductions in levels of service use. Overall the reconfiguration had relatively little impact on the level of use of the NHS acute hospital facilities by local populations. Hospital use by residents of Wyre Forest was little affected by the reconfiguration of Kidderminster hospital in September Emergency admissions declined slightly in each of the two subsequent years before rising to above the previous level. The decline in emergency admissions was offset by increased nonemergency admissions. Use of Kidderminster hospital by Shropshire residents reduced after configuration as Shropshire Strategic Health Authority shifted contracts. Despite the reconfiguration, Kidderminster hospital continued to treat considerable numbers of patients, down from 17,000 in 1999/2000 to around 11,000 in each of 2001/2 and 2002/3 but projected 2 to increase to almost 14,500 by 2005/6. The changes comprised sharp falls in inpatient activity offset by increasing use of non-emergency day case surgery. Kidderminster hospital in 2004 provided mainly non-emergency day case surgery and was planned to become one of the new specialist NHS Treatment Centres, serving a wider population. Kidderminster hospital has thus changed from being the dominant provider of local hospital services (69% of Wyre Forest admissions in 1999/0) to a minority (35% in 2002/3). The total number of beds in Worcestershire fell slightly (2%) in the year after the reconfiguration with further year-on-year changes leaving the 2003/4 total 5% below that in 1999/2000. Acute beds fell by more - 9% in the year after the reconfiguration and by 15% between 1999/2000 and 2003/4. The decline in acute beds was offset by reduced length of 2 In the review of Kidderminster hospital by Professor Darzi See page 31 for details. 11

12 stay such that the number of patients treated in Worcestershire hospitals in 2003/4 was only 1% below that in 1999/2000. As the number of A&E departments in Worcestershire was reduced from three to two, the total attendances fell by around 12%. However, when attendances at the new Minor Injuries Unit (MIU) in Kidderminster are included, total attendances grew over the period. Attendances by Kidderminster (Wyre Forest) residents at the MIU in 2003 were around 80% of those at the A&E department before its closure. A review of the available data on clinical safety, complemented by inquiries to all clinicians working in the NHS in Worcestershire, revealed no examples of adverse clinical events that could be attributed to the reconfiguration. Similarly, the socio-economic impact on hospital staff of the reconfiguration was relatively small, reflected mainly in change of place of work for some NHS hospital staff from Kidderminster to Worcester. The perceptions of professionals and key stakeholders were mixed. The consultation process on the reconfiguration was universally considered to have been poor. This lack of connection with the PFI redevelopment of the Worcester hospital was also widely criticised. However, many doctors considered the reconfiguration to have had positive effects. Consideration of the extent to which Kidderminster was unique suggests two main factors: the quality of the campaign to save the local hospital, including leadership by local clinicians, and the weak leadership of the NHS in Worcestershire. The strength of local opinion, at least in part, reflected these factors. 12

13 CHAPTER 1 Background and Research Methods Introduction 1.1 In 2000, Community Healthcare Audit and Research Trust (CHART) 3, a freestanding charity, commissioned an objective study of the reconfiguration of the health services in Kidderminster, Worcestershire. CHART formerly Health Watch was formed in response to local concerns about the future of health services in the Kidderminster District General Hospital locality. Some of the leading figures in CHART had previously been active in Health Concern, the group which led the campaign to save Kidderminster hospital. A research protocol was developed to monitor and evaluate the effects of the reconfiguration (Appendix 1). After an open bidding process CHART commissioned the evaluation from a team at the Health Services Management Centre (HSMC), University of Birmingham, led by Professor James Raftery. This project, which commenced in June 2001, is reported here. 1.2 The terms of reference of the study which focused on the health community formerly served by Kidderminster hospital were to: review the clinical safety, economic and social impact of the NHS reconfiguration in Kidderminster, and assess the impact on perceptions of health professionals, patients and the population of Kidderminster and surrounding areas. The key issue of clinical safety was to be explored by two methods: monitoring changes in the levels of use of health services by the relevant local populations, and exploring in interviews and surveys the effects of any reductions in levels of service use. 3 CHART (Community Healthcare Audit and Research Trust) developed, via an arms length body Health Watch, from Health Concern the public campaign group developed in 1998 as a response to Worcestershire health service reconfiguration. Each of these groups was led by local retired hospital consultants and GPs. 13

14 1.3 A project management group supervised the research, consisting of members of CHART; an external academic advisor from Leicester University 4 ; and HSMC staff. Interim analyses and investigations were provided at three-monthly intervals for the Project Monitoring Group. Methods 1.4 Quantitative and qualitative methods were used as follows: review of all documents produced by all Worcestershire health organisations 1992 to 2004, analysis of routine data including the Hospital Episode Statistics (HES), waiting times data, complaints data, and local databases, interviews with key stakeholders, from June 2001 to December 2003, two postal surveys of Worcestershire GPs and consultants in 2001 and 2003, analysis of relevant national surveys including National Patient Surveys and NHS performance indicators, comparisons with other relevant NHS reconfigurations, 1993 to During this research the NHS has experienced considerable change, including policy initiatives, clinical practice changes, increased patient expectations, recruitment problems and partial implementation of the European Working Time Directive on Junior Doctors 5. This research has attempted to take these changes into account while focusing on the terms of reference. Limitations and Barriers 1.6 The main limitations both in terms of access to people and data were due to the non-cooperation of Worcestershire Health Authority and Worcestershire Acute Hospitals NHS Trust, both of whom refused to be involved with the project. 1.7 Worcestershire Health Authority (WHA) in its refusal to participate cited its disagreement with the study s methods, arguing that a control group was necessary to enable robust comparisons to be made. This was not possible both 4 Independent, external academic advice for CHART on the progress of the research project was provided by Leicester University, initially Dr Gillian Parker, later Dr Janet Harvey. 5 EUWTD was originally agreed by the European Community in 1993 and became part of UK employment law in 1998 as a health and safety issue. It specifies that junior doctors will come within its ambit in August 2004 and was originally agreed by the European Community in

15 because the research was retrospective and it was not clear how a control group might be selected. 1.8 Worcestershire Acute NHS Hospitals Trust, which incorporated the Kidderminster hospital from 1999, also initially refused to be involved with this research. This stance softened in 2001 when it agreed to allow hospital consultants to be surveyed. The appointment of a new Chief Executive in late 2003 led to increased co-operation with the study, but too late to provide much input. 1.9 From its inception in April 2001, Wyre Forest Primary Care Trust (PCT) provided limited support but had limited access to data covering previous years Worcestershire Local Authority was also invited to participate but declined. Health Services in Worcestershire 1.11 Worcestershire Health Authority served a population of 540,000 in (Map 1). Three acute hospitals existed then, one in each of Kidderminster and Redditch in the north of the county and in Worcester in the south. Smaller Community hospitals existed in Bromsgrove, Evesham, Malvern, Pershore and Tenbury. Although the acute hospitals have been merged and reconfigured, the community hospitals continued in 2005 to function largely as before. 6 Growing to 544,000 in 1999 and a projected 570,230 by

16 MAP Worcestershire is bordered on the north and north-east by the Black Country and Birmingham and on the west and south by largely rural Shropshire and Gloucestershire. A relatively affluent county, more than three quarters of its population live in electoral wards that are among the 40% most affluent in England. Pockets of severe deprivation exist, however, with four wards featuring in the 20% most deprived in England. One of these, Oldington and Foley Park, in the Wyre Forest district, is among the 10% most deprived in England The Wyre Forest District, in which Kidderminster is based, has a population of 96,700 7, 18% of the population of Worcestershire. Kidderminster town with a population of almost 55,000 is the area s main commercial heart. Despite industrial decline including rationalisation of carpet manufacturing, Wyre Forest diversified into luxury boatbuilding, ceramics, and engineering and other hightechnology industries. The other main towns in Wyre Forest are Stourport and Bewdley, each surrounded by commuter belt villages and farms Office for National Statistics. 16

17 1.14 Kidderminster Healthcare NHS Trust was formed in 1993 as part of the third wave of NHS Trusts under the 1991 Health and Social Care Act. It provided health care to a population of around 130,000 covering Kidderminster and the surrounding area as well as parts of Shropshire and South Staffordshire. Employing 1,300 staff, the Trust incorporated the services directly managed by the former Kidderminster and District Health Authority, including mental health, community and general acute services. The main purchaser for Kidderminster NHS Trust was the newly formed (April 1994) North Worcestershire Health Authority. In April 2000 the Trust was merged with Worcestershire Acute Hospitals NHS Trust which six months later closed the A&E department and relocated acute inpatient 8 (other than day case) beds. Mental health services became part of the Worcestershire Community and Mental Health Trust. However, Kidderminster hospital continued to function in 2004 providing mainly elective surgery and a minor injuries unit Up to September 2000 Kidderminster hospital provided district general hospital services through 202 acute beds 9 covering both emergency and non-emergency admissions. The range of specialities had narrowed over time due to the loss in 1996 of acute paediatric services and consultant led obstetrics. Capital investment in Kidderminster hospital site during the mid 1990 s included a 14 million new build between 1993 and Besides NHS investment, an active League of Friends provided over 2m for equipment and building In 1996 the existing three Worcestershire health authorities (North Worcestershire, Bromsgrove and Redditch and South Worcestershire) merged into a single countywide Worcestershire Health Authority (WHA). The new organisation sought to reduce costs by 9 million per annum to remain within its financial allocation and wipe out an underlying deficit projected to reach 18 million by March These financial problems dated from the early 1990 s and were attributed to: a high percentage of GP Fundholders (see below) high levels of patient referrals out-of-county at higher cost 8 Up to 2000/1, The NHS classified beds as acute, geriatric, mental illness and maternity. Acute hospitals beds could be disaggregated between inpatient and day case beds. Inpatient beds are used by both emergency and non-emergency admissions. A more detailed breakdown by ward type is available from 2000/1 and used in Chapter 5 below. 9 There were also 80 mental health and EMI beds on the Kidderminster Hospital site, which became part of the Community and Mental Health Trust in April

18 health demands associated with rurality some patients from areas of extreme deprivation inadequate funding to support the newly opened Alexandra hospital in Redditch An independent financial review 10 in 1996 advised Worcestershire Health Authority to take early action to reverse the increase in out-of-county patient flows although savings from this course of action were only estimated at 500,000. It was also urged to take strong action with the four NHS Trusts in the county to reduce costs and help the Health Authority achieve financial balance Kidderminster hospital, prior to 1996, had not experienced any serious financial issues, which affected the rest of the county, as its predecessor health authority, North Worcestershire Health Authority, had maintained financial balance. The development of a large number of North Worcestershire 11 GP fundholders, immediately after the 1991 reforms, with early, advantageous funding formulae, may have disguised these deficits. Fundholding, it is claimed, fostered a high degree of co-operation between Kidderminster hospital and local Wyre Forest GPs. Services at Kidderminster Hospital were considered by local clinicians and the public to be of a high quality and well integrated with primary care. As the health authority was considered to have been prudent, the emerging financial deficit was considered to have come from elsewhere. Early discussion in Kidderminster on the county-wide financial problems focussed on the possible impact on the hospital in Kidderminster. The main NHS organisations are summarised in Figure SECTA The Financial state of Worcestershire Health Authority. External Consultants commissioned by Worcestershire Health Authority and the West Midlands Regional Office In Kidderminster and surrounding areas. 18

19 Figure 1.1 Main NHS organisations in Worcestershire Kidderminster Hospital Trust } Alexandra Hospital, Trust Redditch } Worcestershire Acute Trust (1999-) Worcester Royal Infirmary } N. Worcestershire Health Authority } Bromsgrove & Redditch HA }Worcestershire } HA( ) Coventry, Warwick, Herefordshire and Worcestershire SHA S. Worcestershire HA } Wyre Forest PCT S Worcestershire PCT Redditch & Bromsgrove PCT 1.19 The organisation of hospitals in Worcestershire was complicated by the failure over many decades to reorganise hospitals in Worcester city. Traditionally the city had two hospitals, which despite merging into a single NHS trust continued to run on two sites until the opening of the new PFI-built Worcestershire Acute NHS Trust in NHS hospital planning was changed by the Private Finance Initiative (PFI) introduced by the conservative government in The plan for a new hospital in Worcester, developed in 1996/97, was in the first wave of PFI projects All commentators agreed that Worcester badly needed a new hospital. When Worcestershire Health Authority came into existence in April 1996 it was immediately embroiled in discussions on the new PFI hospital in Worcester. The PFI proposals envisaged centralising the two Worcester city hospitals on one site, with implications for the other hospitals in the county at Kidderminster and Redditch. It initially suggested it would require fewer acute beds across the county with an estimated ongoing savings of 4.6 million per annum (in Worcester) together with 3.7 million elsewhere in the county (mainly Kidderminster) In late 1996 the new Worcestershire Health Authority launched a countywide strategic review of health services. It noted key factors affecting all hospitals: increasing sub-specialisation which could lead to the loss of accreditation for junior doctor training in some specialties; and, difficulties in providing safe 12 Numbers of beds were based on calculations for an 85% bed occupancy and an average length of stay of 3.5 days 19

20 levels of care for critically ill patients across three sites. In 1998 it issued the consultation paper Investing in Excellence which suggested (see 1.29) merging the three acute trusts in the county into one Subsequently, Worcestershire HA was instructed by the Health Minister (December 1998), to begin consultation on the merger of the three Acute Trusts; Kidderminster, Alexandra (in Redditch) and Royal Worcester, as part of the implementation of Investing in Excellence. This merger took place in April 2000 six months before the reconfiguration of services across the acute hospitals which included the removal of acute medicine and surgery and a full A&E service from Kidderminster hospital. The Health Authority argued that financial problems were only one facet of a complicated series of policy issues needing urgent resolution. In particular, it was widely anticipated (by WHA, the West Midlands Regional Office and by the majority of clinical staff) that changing clinical practice if not planned would create problems and compromise acute services The fragility of medical staffing levels in both Kidderminster and the Alexandra hospitals had been emphasised in the mid-1990s by the West Midlands Regional Medical Task Force. Inadequate medical staffing levels, it warned, would lead to removal of medical training accreditation. This related mainly to the Alexandra hospital at Redditch (and trauma and orthopaedics at Worcester Royal). Kidderminster hospital had fewer recruitment and retention problems although its viability in a number of specialties had been questioned by the Royal Colleges. The Health Authority argued it was untenable to address the financial options alone whilst leaving such clinical issues to a later date. The scale of change needed to address financial, clinical manpower and medical subspecialisation problems were seen to be of such magnitude as to require substantial organisational service reconfiguration What had emerged as a key issue, largely ignored in clinical and public discussions at the time 13, was the implementation of the European Working Time Directive (EUWTD). This had been signed in 1996 and implemented within Health and Safety Legislation in the UK for most employees in 1998 but with a derogation order for certain groups including doctors until August The numbers of junior doctors required to replace the hours of duty lost in the 13 This was not mentioned for instance in Investing in Excellence. 20

21 EUWTD 14 would have been around 4 times the 1998 total of five in Kidderminster. Either Kidderminster hospital would need to acquire many more medical staff or change the services it provided In Kidderminster, local concerns centred on fears that Wyre Forest and Shropshire residents would see a diminution of service and staff. A campaign to protect the Kidderminster hospital developed from around In 1998 the campaigners commissioned a local population survey by MORI 15, subjected the Worcestershire Health Authority plans to judicial review 16, and delivered a 40,000 signature petition to Downing Street. In 1999 the campaigners formed Health Concern David Lock, Wyre Forest MP from 1995 ended his earlier support for the campaigners in In August 1999 he issued a public statement in which he talked about his constituency achievements since his election and his stand on the changes in Kidderminster: The campaign against any change (at Kidderminster Hospital) was misconceived from the start and never had any informed support. I believe my duty as a Labour MP was to promote what was right and medically defensible, not to follow the latest popular whim or chase a populist agenda In Spring 1999 health campaigners took the decision to enter politics as Health Concern. Their candidates in the May 1999 District Council elections won seats, both in Wyre Forest (7) and South Shropshire (4) Health Concern felt that this electoral success provided a pivotal platform. When John Hutton, Health Minister visited Worcestershire in June 1999 Health Concern was included in the group to meet the minister. The minister then invited them to meet him privately later in the year in the Department of Health (September 1999) when the Kidderminster delegates presented him with the supporting arguments and a list of issues in which they compared with 14 New Deal - Protected Training Time for Junior Doctors Department of Health 1998 Seminar Hospital of the Future Department of Health July Funded by the League of Friends and the Community Health Council. 16 The judicial review written application was refused in December 1998 and an oral application in January The statement continued: That principled approach has led to criticism but now the plans are unfolding, supported by local GPs and the hospital consultants themselves, public opposition to the changes is dropping off, even the health campaigners accept that nine out of ten people will continue to be treated at Kidderminster MP for Wyre Forest August Since 2001 Health Concern Councillors have controlled Wyre Forest District Council and maintained seats on the County Council. 21

22 reconfiguration of hospitals elsewhere in the UK. Health Concern highlighted shortcomings and argued for: agreement to ensure effective local representation the extension of patients treated to include those with length of stay up to five days consultant cover for the local emergency centre to include a medical presence during the active day period a research exercise to evaluate novel service changes such as tele medicine and ambulatory care independent monitoring of service provision The minister provided 19 a comprehensive reply to these points, claiming that key figures were incorrect, specifically; I am concerned that some of your worries may have been based on incorrect assumptions. In particular, your population figures and the current bed numbers quoted are incorrect. Whilst the total number of beds within Kidderminster General Hospital is around 300, these include beds in Tenbury Wells, which will remain, and inpatient adult psychiatry which is to be reprovided leaving around 200 staffed beds (in use) at Kidderminster Hospital. Other aspects of the minister s response included criticism of comparative data used by Health Concern. Health Concern considered this response flawed. By dismissing many of their points it reinforced their determination to continue the struggle Soon afterwards a consultation document was issued (November 1999) about merging the three acute trusts in the county. In Kidderminster both clinicians and Health Concern supported the merger The reconfiguration of services at Kidderminster hospital was implemented 18 months earlier than originally planned, in September 2000 and not April The reason given was the resignations of a number of key clinical staff concerned about their future at Kidderminster, so threatening clinical viability. The new Worcestershire Acute Trust Board 21 stated that it would be better to get 19 Letter to Health Concern 1 st October Letter from Kidderminster NHS Trust Medical Director to Trust Board February Worcestershire Acute Trust Board discussions February

23 the merger over and done with and give everybody the opportunity to get his or her fair share of the facilities in the new (PFI) hospital 1.32 In the general election of 2001, Dr Richard Taylor, a retired consultant physician formerly of the Kidderminster hospital, successfully contested the Wyre Forest seat as a Health Concern candidate, replacing Mr Lock A more detailed chronology of the complex history, including consultations, evolution of campaign groups, commissioning of external reviews/reports, referral to the Secretary of State for Health, political negotiations, and the election of the Health Concern independent MP for Wyre Forest in May 2001 are documented in Appendix 2. Summary 1.34 The long overdue reorganisation of hospital services in Worcester city, which commenced in the 1990s, had implications for the two smaller hospitals in the county at Kidderminster and Redditch. The Worcester city hospital plans were largely confidential under the new Private Finance Initiative. Worcestershire Health Authority proposed merging the three hospitals on grounds unconnected to the redevelopment of the Worcester hospital. On April 1999 those campaigning to save the Kidderminster hospital, frustrated by the NHS consultation processes, formed Health Concern which successfully contested first local and then national elections. 23

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25 CHAPTER 2 The context: reconfiguring the NHS in Worcestershire The National Context 2.1 In 2002 some 75% of English hospitals were involved in some form of reconfiguration debate that is discussions about where and how secondary and tertiary services were to be provided 22. The Royal College of Surgeons 23 proposed 24 that acute inpatient care should be provided in fewer, larger, better equipped, and better staffed hospitals. The Royal College of Physicians proposed the phasing out of acute emergency admissions from isolated smaller units and transfer the work to properly equipped and staffed larger units. 2.2 The Kidderminster story is partly a result of attempts to implement the Royal Colleges proposals. The role of the Private Finance Initiative in the re-provision of the Worcester hospital also plays a part. The story also raises the issue of how the NHS consults in health service reconfiguration. 2.3 This section first reviews how the NHS consults along with recent changes in these processes. It then compares the consultation process in Kidderminster with that in other reconfigurations. The role of the PFI is discussed in Chapter 3. NHS Consultation 2.4 The process of NHS consultation can be summarised as follows: the Health Authority (HA) draws up a plan with options for change each of which is apprised and costed following Treasury guidelines, this plan is then issued for public consultation, at the end of the consultation period, the HA reviews the responses, and amends the plan, as appropriate and necessary, it then proceeds to implement the plan unless an appeal is made to the Minister, or failing that, the Courts. The establishment of the Independent Reconfiguration Panel, in April 2003, marked a change in NHS consultation which is explored later in this chapter. 22 Black, A. Reconfiguration of surgical, emergency, and trauma services in the United Kingdom Centralisation of services is politically impossible. BMJ 2004; 328: (24 January), doi: /bmj Senate of Surgery of Great Britain and Ireland. Reconfiguration of surgical, accident and emergency and trauma services in the UK. Glasgow, Royal College of Physicians. Isolated acute medical services. London: RCP,

26 2.5 From 1996 to 1998 many models of health service delivery were debated often stimulated by the various Royal Medical Colleges. The acute hospital sector was undergoing upheaval, with many trusts and health authorities contemplating or embarking on rationalisation or reconfiguration programmes. Common reasons for change included; advances in medical technology, reduced lengths of stay, specialisation of clinical training, fewer clinical staff, more conditions being treated in the community, and an increasing range of treatable conditions. 2.6 Underlying these concerns was a belief that quantity and quality were linked. Low volume was believed to lead to poor quality and vice versa. A systematic literature review by York University 25 found no statistical association between quality of care and the size of hospital or the amount of work undertaken by doctors. Despite substantial evidence that for some procedures or specialties there may be quality gains as hospital or clinician volume increases the review concluded that there was no direct causal link between volume and outcome. This finding had little impact on the beliefs of policymakers or the Royal Colleges, which continued to claim a relationship between quantity and quality. 2.7 The White Paper The New NHS Modern Dependable 26 in 1997 marked the new Labour Government s first major contribution to NHS policy. It focussed on the development of primary care commissioning groups and emphasised a primary care led NHS. Some of the Royal Colleges saw this as: a threat of disinvestment in secondary health care services it is therefore considered appropriate to offer co-ordinated advice on the provision of emergency and urgent care in units of differing size. 2.8 The resulting joint Royal College consultation documents Provision of Acute General Services 27 (1998) re-iterated its recommendations. The relevance of each of these factors in the Worcestershire health debate is italicised below; 25 Concentration and Choice in the Provision of Hospital Services CRD Report 8. Sheldon T et al. University of York Department of Health. The New NHS Modern Dependable. London: HMSO: December The Royal College of Physicians of London, the Royal College of Surgeons of England. Provision of Acute General Hospital Services Consultation Document. British Medical Association London: July

27 The present distribution of hospital units providing acute and emergency medical and surgical care needs to change if patients are to benefit fully from recent advances in acute care (a point constantly made by WHA in their proposals for the total health community) The ideal unit for fully comprehensive medicine and surgery is a hospital or integrated group of hospitals serving a population of 450,000 to 500,000 (Worcestershire population was 560,000) The effective size to provide most of the acute services of medicine and surgery is one serving a population of 250,000 to 350,000 (the population served by Kidderminster was around 130,000) There should be no single-handed consultants in any of the major medical or surgical specialties regardless of the size of hospital (several minor specialties at Kidderminster had single-handed consultants. Further medical sub-specialisation would have worsened the position) District general hospitals situated in areas of the country where it is not practical to amalgamate with others will need to continue for the foreseeable future. The smaller the acute unit, the greater should be the co-operation with adjacent acute hospital units, both professionally and contractually, in order to provide sustainable high-quality specialist care for patients (a point constantly argued by the Kidderminster community and medical pressure groups) There needs to be a major expansion in the number of consultants in order to provide up-to-date high-quality medical and surgical services (agreed by all parties) It is not possible for each locality to have its own acute hospital and accident and emergency unit (the A&E unit in Kidderminster hospital was closed in September 2000). Quality should be the primary consideration when planning services (Argued by all parties). 27

28 The contrast is clear between the views of the Royal Colleges, endorsed by the NHS in both Worcestershire and England on one hand, and on the other, those of the campaign to save the hospital in Kidderminster. Reconfiguring the NHS in Worcestershire 2.9 Kidderminster hospital had managed to retain clinical services throughout the 1990 s despite a number of challenges. First, under the New Deal 28 on junior doctors hours, Kidderminster hospital began to lose recognition of training posts. The West Midlands Regional Postgraduate Dean and the New Deal Task Force developed protocols, which were later used as models of best practice nationally. By the mid-1990s the Post-graduate Dean 29 and a number of senior clinical 30 staff at the Regional Office had concerns about the future clinical viability of Kidderminster Hospital. Paediatric junior doctor accreditation was withdrawn from Kidderminster hospital in 1996 and obstetric in Kidderminster had experienced consultant staffing problems 31 in the A&E department for some years, although several consultants interviewed stated that this situation was compensated for by the willingness of all consultants to be present in A&E for serious emergencies Secondly the publication of the Calman Report 32 on specialist medical training set out a new way of training junior doctors. Difficulties in the implementation of new shift patterns were to be alleviated by clinical networking 33 between Kidderminster and Worcester hospitals. The loss of support leading to paediatric and obstetric accreditation meant that there was insufficient specialist medical manpower for a full A&E department in Kidderminster. Around this time, the development of a managed clinical network enabled certain emergency vascular patients to be referred to Worcester Thirdly, the Calman-Hine report 34 (1995) recommended the establishment of cancer centres served by specialist staff. The Calman-Hine recommendations created little clinical debate at Kidderminster as major cancer surgery was already taking place elsewhere (notably head and neck and cardio-thoracic). However, regional Calman-Hine reviews highlighted gaps in specialist services 28 Department of Health The New Deal on Junior Doctors Hours January Personal Interview November Personal Interview - February June Kidderminster NHS Trust Board papers. 32 Calman K. Hospital doctors: Training for the future: The report of the Working Group on Specialist Medical Training. London: Department of Health Clark,J. Spurgeon,P. Clinical Networking. HSMC, Calman K; Hine; Report by the Expert Advisory Group on Cancer to the Chief Medical Officers of England and Wales (Calman-Hine report) Department of Health

29 in Kidderminster hospital. A successful fund-raising campaign by the League of Friends to provide a purpose-built chemotherapy centre at Kidderminster Hospital was launched in The use of this centre, for outpatient and day care continued in 2004 although clinical staffing remained under review Worcestershire Health Authority s proposals in 1997/98 35 suggested that Kidderminster hospital would retain general medicine, medicine for the elderly, day case surgery, maternity and children services, together with all pre-existing outpatients, and pathology and radiology. Campaigners contended that this would result in the closure of the majority of acute inpatients services which would not be viable without twenty-four on-site surgical backup. This view was shared by physicians 36 in Kidderminster. The Health Authority rejected this, arguing that it would be possible to provide acute medicine by a service model such as that operating at Solihull and St Cross hospitals, Rugby, which had been approved by the relevant Royal Colleges In early 1998 differences in clinical opinion in Worcestershire became more marked and seemed unlikely to be resolved at the local level. The Community Health Council proposed that the reconfiguration plans proposed by WHA be reviewed by an independent external clinician. This review took place with representatives from various Royal Colleges, West Midlands review teams, the Regional Director of Public Health and the Regional Postgraduate Medical Dean but was never published 39. Worcestershire Health Authority claimed the review had concluded that acute services could not be maintained at Kidderminster Hospital at the current level. Unsurprisingly, this was rejected by the Kidderminster campaigners. Models for Sharing / Distributing Clinical Expertise 2.14 Given the impending shortage of clinical staff, models for sharing staff between hospitals became important. The main alternatives available were hub and spoke as used by Investing in Excellence and clinical networking as used in the Scottish Acute services review These proposals were not presented in public. 36 Letters from Kidderminster Consultants. 37 This model of clinical networking does not appear to have been notably successful as evidenced by the need for a later review of emergency services at Solihull (as part of Heartlands and Solihull NHS Trust). 38 The Health Authority accepted that the distances between Solihull and Heartlands hospital (on the east of the Birmingham conurbation) and St Cross and Walsgrave hospital, Coventry were less than would be the case in Worcestershire (18 miles from Kidderminster to Worcester) but did not consider this a serious barrier. A further complication had to do with the better access to surgical support in Solihull/Rugby compared to Kidderminster/Worcester. General medicine was not one of the specialties under review. 39 This review did not figure in subsequent discussions when Health Concern were pressing for an independent review. 40 Scottish Office. Acute Service Review Paragraph

30 2.15 During the Worcestershire consultation the term 'hub and spoke' was seen by the Kidderminster campaigners as implying subordinate status for the 'spoke' and for primary care. Although 'hub and spoke' can describe arrangements under which patients are transferred to a more central unit when no local specialist is available, it does not encourage the development of expertise in the 'spoke', nor does it include exchanges of staff for training and the maintenance and enhancement of competence. A network, by contrast, can facilitate these. In short, the use of hub and spoke by WHA fed into the fears of the campaigners that Kidderminster would be downgraded in favour of Worcester. Other reviews and actions during consultation 2.16 King's Fund review was commissioned by Kidderminster CHC and Health Concern in early In brief this suggested that Kidderminster hospital should provide: an ambulatory care centre operating at least 12 hours per day with 25 places approximately 60 step down, GP medicine and rehabilitation beds a Minor Injuries service open 8am to 10pm possibly extendable to 24 hour consultant led if other conditions were met a cancer care centre ultimately offering hospice beds that some inpatient elective surgery (25+ beds), possibly in Orthopaedics and Urology, should be retained at Kidderminster, reducing bed requirements in Worcester. Under these proposals Kidderminster Hospital would have retained beds including a substantial range of medical and surgical services These proposals were rejected by the Kidderminster campaigners as lacking an acceptable model of emergency service provision. The King s Fund review group considered this rejection inappropriate, not least as it would have retained a much wider range of service provision at Kidderminster hospital than the 1996 Investing in Excellence proposals After this rejection (May 1998) Kidderminster CHC indicated its intention to submit a formal objection to the Secretary of State for Health. In order to prevent this, the WHA 41 sent a letter to the CHC offering a different model of 41 Letter 13 th May 1998 to CHC Chair from CE Worcestershire Health Authority. 30

31 Kidderminster service provision in the light of re-examining the King s Fund proposals, discussions with clinicians and elsewhere. that additional services were acceptable. It offered to develop a new model of care with additional beds in Kidderminster hospital. This new model was also rejected by the Kidderminster campaigners as well as by the CHC. Comparisons with other hospital reconfigurations 2.19 During the evolution of Keeping the NHS Local various other innovative models were under debate nationally and locally. In response to a request from Worcestershire Acute Trust a review was undertaken for the Department of Health by Professor Ara Darzi 42. Professor Darzi had been asked to review surgical services within the context of smaller hospitals such as Kidderminster and Bishop Auckland (Durham). This review, welcomed by Health Concern as possibly the external clinical review long requested, was published in June Professor Darzi proposed an additional 5-day elective surgical ward with 25 beds in Kidderminster in conjunction with extension of the proposed Treatment Centre facilities. His projections indicated that when fully functioning this facility would increase the number treated in the hospital to around 85% of that prior to reconfiguration In parallel to the publication of Keeping the NHS Local the Department of Health also established the national Independent Reconfiguration Panel (IRP) to provide a new source of independent advice on contested major service change in the NHS. The panel delivered their first report 43 for East Kent in July The East Kent reconfiguration followed a parallel timescale with Worcestershire, starting in 1997/98. Its three hospitals served a similarly sized population. A review of Worcestershire and East Kent examined against the tool kit developed by the Independent Reconfiguration Panel (IRP) showed the similarity of the patient and public involvement in the two reconfigurations (available from authors) The models for re-provision of services in East Kent (which retained inpatient medicine) were not substantially different to those finally implemented in Worcestershire. However, the IRP suggested the three main acute hospitals should work interdependently, each contributing specialist services when such 42 Professor Ara Darzi was Professor of Surgery at Hammersmith hospital, London and surgical services advisor to the Department of Health. 43 Independent Reconfiguration Panel report on East Kent Department of Health, July

32 services could not be provided in all three. This is closer to the concept of a clinical network than that of hub and spoke as proposed for Kidderminster PFI played an important role in East Kent, particularly in relation to estate improvement and rationalisation. The IRP suggested that a longer term strategy will be required to meet all estate renewal requirements ; that the current PFI should be abandoned.with the possibility of a new PFI only considered once the Trust has reached a position of greater financial stability Another instance of NHS reconfiguration was in south London. The King s Fund review of Kidderminster drew attention to the proposals to close Queen Mary s hospital, Roehampton and transfer of services to local hospitals. The two local health authorities (Kingston, Esher and Merton HA and Sutton and Wandsworth HA) had begun the process by consulting and involving key clinical staff in drawing up their proposals, but did not consult either the local population or GPs. Assumptions as to how local residents and GPs would respond to the closure of the Queen Mary hospital proved flawed. The later involvement of local GPs produced a revised set of proposals 44 which went out to consultation Bishop Auckland hospital, Durham provides another example. As part of the modernisation agenda the Department of Health established pilot schemes that have been set up to evaluate various models of service provision. Bishop Auckland was one of the hospitals which were cited in discussions during consultations on Investing in Excellence in 1998, as comparable to Kidderminster. As one of three traditional district general hospitals serving a large rural area with a population of 125,000 in County Durham its clinical sustainability was in doubt. This in turn presented major capacity issues in the other two County Durham hospitals. In the light of these pressures, Professor Ara Darzi was asked to advise on clinically sustainable options across the county in On the basis of his review, the local NHS developed services based on the three Durham hospitals working together as one integrated health system NHS guidance, in February 2003, by the Department of Health, Keeping the NHS Local A New Direction of Travel 45 acknowledged flaws in the process by which the NHS consults the public on hospital reconfigurations: it challenges 44 Worcestershire Local Medical Committee letter to Secretary from Worcestershire Health Authority Chief Executive, May Keeping the NHS Local A New Direction of Travel - Department of Health, February