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
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
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
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