What Is It?
- A plan to change services and provision across Kent and Medway (K&M)
- Driven by NHSE Chief Exec Simon Stevens “Five Year Forward Look”
- Organised by NHS top brass in Kent supported by NHSE staff
- Started in 2017 with intent to have service changes in place by 2020-21
- Core assumption is that existing services here are financially unsustainable
- And that rising demand (eg for elective operations and increasing A&E admissions) makes them even less sustainable
- All based on Govt. funding increases of c. 1% in NHS budget when NHS inflation is at 4.5%
- Therefore, growing gap between reality and budget provision………..
- ….And the gap will continue because Govt will fail to increase NHS spending to meet rising demand
- Core assumption of STP is that acute admissions to hospital beds, and attendances at A&E, and outpatient activity and tests, can be reduced by “administrative measures” and by improved community services
- Real evidence for this cost reduction is thin – but admin measures can create more waiting time and therefore slow down costs
- What’s the gap? Their figures assume £486 million A YEAR shortfall in cash available across K&M by 2020-21 if nothing is done
- And they have confirmed that this figure will be EXCEEDED
How Do They Propose To Close The Gap?
- 60% of the cost overrun is in acute hospitals, they say. Initial figure is to take out £160m from hospitals by 2020-21. And now they say the shortfall is worse than that
- How do they do this? 80% of all costs are staff. Some Trusts have multiple complex sites. Best assumption is that they will have to:
- ÉReduce staff overall
- ÉClose or partially close some sites
- ÉReconfigure services to reduce costs
- ÉMerge or concentrate GP practices
- ÉSpend to save, eventually, by using capital spend
- ÉReplace acute services by more community services to keep people in their homes
- ÉSlow down activity ie admissions, tests, A&E
- There is no evidence that all this can be done by 2020-21. And they agree.
- Common sense NHS assumption is that this will take many years and go through multiple iterations as planning and cost assumptions change
- Key planning assumption is that activity will have to be reduced across services by 13-16%. This means fewer patients being referred for operations, tests and treatment
- Even they say it could all go wrong: “sensitivity analysis” shows that K&M deficits could stay at -£382m in 2020-21 if pace of change is slow. And it will be.
- AND they haven’t taken in to account new mental health spending requirements
- In meantime, if the STP plan is slow, local Trusts with a running deficit (eg E Kent Hospitals) will have to make in year savings to pay off loans from DH to cover their costs
- Conclusions:
- It is finance driven not quality driven
- It will stop patients getting treatment
- It is mad on timescales
- It may involve big capital spending that might not be available
- It will mean redesign of services, staff reallocation, that will take years
2017 Budget Impact: Minimal
- Significant delays already but they are pressing forward with detailed planning and options in advance of consultation
- Their objective is to close off the options so that the public has little choice
- Core problem for them is to create mass community services to deal with obesity, diabetes, patients with complex needs. Effectiveness depends on rapid uptake amongst working class. Unlikely.
- Plans affected by 2017 Budget: NHSE allocated extra £1.6bn for 18-19. Of this, £1bn earmarked for reducing waiting time for electives and £0.6bn for reducing 4 hr waits in A&E
- Also, £335m winter pressures fund for this year – too late to have a significant effect
- Before new money kicks in we will see mass deferral of elective work till April
- Likely to see repeat of NHS Improvement’s 2016 order to cut all elective ops this Winter in order to protect 4 hr wait and admissions from A&E
- These won’t show up in stats if they are not booked in the first place. New system in East Kent stops GPs referring directly for orthopaedic ops – instead have to refer to a screening service to assess severity. Result: reduced flows in to the system, much slower
- New money in 2018 won’t be enough to restore the 18 week maximum wait. Some CCGs introducing minimum waiting times
- Much of the new money likely to go to sub contractors ie private provision because NHS has so little capacity (theatres, staff etc)
- No ringfencing of any of this so it could all leak away
Key Problems
- Timescale unachievable
- Can only proceed if they have pump priming funds to create replacement services
- Cost savings will only work if new queueing systems created (ie multiple queues before 18 week clock starts)
- Some “community services” will depend on an underpowered voluntary sector
- “Any Qualified Provider” may mean greater scope for private sector in all new services
- Capacity loss is staggering: plan is to reduce hospital beds by 460 at a time of rising demand
- STP pump priming cash only used to plan and to create new services – and not to cover growing existing deficits
- They haven’t worked out population segmentation ie scale of needs, so cost assumptions are weak
- Because patient flows East to West Kent are minimal, they’re going to consult on urgent care, emergency care, acute medical services, orthopaedics in E Kent alone – to start with
- “Hurdle Criteria” established to winnow the choices: clinically sustainable; implementable; accessible; strategic fit; financially sustainable.
- Hurdles analysis show that the choice boils down to these “logical” options:
- William Harvey: major A&E with specialist services
- QEQM: smaller A&E (emergency centre)
- K&C: urgent and elective care
- Could include consolidation on to one site; or two sites by closing one; or new greenfield site
- BUT: completion of the plans by 2020-21 makes new build on a greenfield site impossible, as is consolidation of all services on one hospital site. Takes 9-11 years to deliver a new hospital and around £665 million.
Key Problems 2
- Access for patients: on a 2 site specification, best access shows 80% of population being able to access services within 30 mins if located at QEQM and WHH
- Costs of turning QEQM in to the larger emergency care centre are very large
- The “Quinn Proposal” to provide a shell hospital building has been added as an additional option to show “reasonableness”
- Options to be considered are therefore two:
- ÉMajor site with specialist services and substantial emergency centre at Ashford; smaller emergency centre at QEQM; and elective care at K&C
- ÉMajor specialist centre and emergency care at Canterbury with Ashford and QEQM doing elective care and integrated care
- Separate list of 7 recommendations to deal with the orthopaedic service
- All of these involve concentration of services
- Are the plans reasonable?
- They are driven by cost and workforce availability
- They just assume that quality will improve if services are concentrated
- They just assume that community services are cheaper and will be effective in keeping people out of hospital
- They accept the original timescales are impossible
- It is clear by their language that they are leaning to their original scheme rather than the Quinn proposal
- These plans are a mess – like most of the STPs
Labour’s Response
- Nationally: call in all the STPs and review them. Perfectly sensible.
- Why do we oppose the Kent and Medway scheme?
- ÉIt’s financially driven. If it wasn’t, their option proposals would be different
- ÉThe scheme is based on false assumptions about the effectiveness of community services and their cost
- ÉIt says little about quality – hugely important given the massive breaches of waiting time targets on cancer and elective surgery and A&E waits, and the breaches of licence, that exist
- ÉIt says almost nothing about mental health and its interaction with other services
- ÉIt says nothing about social care and improvements to discharging patients from hospital
- ÉThe timescales are impossible and will lead to chaos
- There are some good points. We should agree to specialisation of services (especially stroke and cardiac) as they save lives, and to the creation of a new Medical School
- Across Kent and Medway, we can all agree to fight the cuts in cash and beds….
- …..And to call for a new plan based on quality improvements and recognition of growing demand, with innovative ways of meeting it.
- The issue of hospital sites in East Kent is more difficult but they will probably land on a preferred option of expanding Ashford, small downward changes at QEQM, and no change to speak of at K&C
- Consultation will start in 2018. Labour’s task is to get thousands of responses in to undermine the credibility of their scheme.
- It can work….look at Lewisham A&E….
The Offer to Help You
- Regular briefings on fast changing situation
- Draft consultation responses as templates for you to use
- Research work on the Kent and Medway MHT, Medway Maritime, Dartford and Gravesham, Maidstone and Tunbridge Wells, and Kent Community Trusts – to support understanding of the specific threats to their services
- Offer of a speaker to your CLP if that would help
- National representations to our shadow health team to inform their view
- Supporting your local comms to the electorate
- Core message: this needs a Labour Government to sort it out
- New services must be based on a sensible workforce plan at national level that trains far more doctors and nurses rather than capping the numbers
- Primary care is critical and we need more GPs in the area
- A realistic STP must be based on improved funding and reform