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