Why would a downgrade to Stafford Hospital matter nationally?
What is happening in Stafford now will set the pattern for
hospitals nationally in the future. It is ingenious the way that hardly anyone
nationally knows the extent of the threat to their services.
What we are seeing here is a battle about what the health
service should look like in the future. The responsibility for finding the way
has been delegated to a team of administrators, led by Ernst & Young, but the
conditions which determine what is possible are set by the government and the
department of health.
Most people nationally will have had their perception of
Stafford coloured by years of bad publicity, some based on highly questionable
material. They will assume that whatever is happening here is just about
Stafford. They would be wrong. In Stafford we have seen this coming for the
last 4 years, and we know that we are being used to set a precedent.
Why did 50,000 people march in Stafford?
When 50,000 people took the streets of Stafford on April
20th for what was probably the largest ever march to save a hospital. We
marched to demonstrate our support for the staff of the hospital, to show that
we value this service and wish to keep it, and to blow the whistle on the
threat to the future of the NHS. We marched because we know we are in a unique
position to see this threat.
You will not have heard that whistle blowing, because frankly
none of us expected the demonstration to be quite on that scale, and the press gave
minimal coverage to this story, which many of them would have found inexplicable.
It is worth taking a look at some of the photos of the event
to get an idea of what this means to a town the size of Stafford. If you have seen them all before then take
another look – just for inspiration!
The group who organised the march and run the Support
Stafford Hospital campaign are unusual. It is a community led group that has
the active support of all major political parties who are choosing to put aside
their differences and work together. The borough councillors voted unanimously
to reject the Monitor proposals on the Hospital. The campaign has the backing
of all major organisations in the town including the churches which are playing
a key role. If you take a look at the extensive video coverage of the march http://www.supportstaffordhospital.co.uk/rallyvids.html
you will see Middle England marching! Many people in their 60s and 70s were taking
part in their first ever protest. Stafford will never see anything like this
again!
The question.of Sustainability
The Administrators after their first bruising public meeting
with 600 residents have been at pains to make it clear that they are here not
because of the supposed “history” of the hospital, but because of “future sustainability”.
This is the argument that is putting the future of around 60
hospitals throughout the country in doubt, and will change the way in which
health care is delivered in every hospital in the country. There are genuine
questions here. We should be having this debate, but we need to do so openly,
honestly, and nationally.
Financial sustainability.
The key reason why the administrators are here is because
the hospital is in deficit. It is deemed to be “not financially
sustainable”. With Stafford there are a
number of unique reasons for that.
·
The two site hospital is currently running with
empty wards that are a drain on resources.
·
Recruitment and retention of staff has been
expensive because of the reputational damage.
·
A one off grant authorised by Andrew Lansley to
help the hospital meet the unique costs of the years of public attention, and
to regain public confidence, was later re-designated as income, which had a
major impact on break even plans.
·
Patient choice and GP recommendations have been artificially
suppressed by the reputational damage.
There is also another major reason which applies nationally.
The Tariffs for acute care are set at a level where they do not cover the cost.
The role of tariffs
This use of Tariffs is deliberate. The DoH wants, probably
quite rightly, to minimise the admissions to A&E and to focus on
preventative care and care in the community, so they have used the Tariffs as a
lever. The only trouble is that the community care is not there, and A&E
admissions keep on climbing, with the result that more and more hospitals are getting
into deeper financial trouble and are struggling to meet the demands on acute
care with insufficient funding. The newspapers are full of stories which
illustrate this problem.
The Hidden costs of downgrades
The pressure to close A&Es, which are the most unprofitable
part of the NHS, is growing. The “temporary” overnight closure of A&E in
Stafford in 2011 (it is still closed) has been accompanied by pressure on the
ambulance service, which is now starting to give us some leaks from Ambulance
service staff who know they are not coping well with this pressure. There is
pressure on neighbouring A&Es where breaches of waiting times, trolley
waits and ambulance waits are regular occurrences, pressure on ICU beds, which
led to one lady being transported to Hereford where she died. The Hospital
reports daily blips in admissions, with large numbers coming in in the morning
when A&E opens, and just before the closing deadline at night. There are
reports of people who delayed calling ambulances, rather than be sent to other
hospitals, and sometimes these decisions have been fatal. The anxiety that many
families feel, especially elderly people and families that have to rely on
public transport, is considerable but hard to measure. For many people who
moved to Stafford the presence of hospital services was a consideration.
Businesses fear the knock on economic effects if we lose acute services, there
are consequences to the entire economy of the town which we do not know how to
calculate.
There is a genuine question here. The accountants who are
making the decisions on the future of Stafford are taking an accountants view.
How do we know that they have added in all the hidden add on costs, such as the
increased costs to the ambulance service? How do we know that they are giving
the right weight to all the quality of life and quality of service issues that
concern the people who will use the hospital? These people have no connection
with the town. They are here to make a quick decision and move on, probably to
the next hospital on the list. They are almost certainly acting in good faith,
but this is complex stuff. There is plenty of room for miscalculation. They
will have no accountability for the unintended consequences of their
actions.
The Myth of Local Decision making
Whilst the government would like us all to accept that
“financial sustainability” is a matter for local Clinical Commissioning Groups,
and local choice, the reality is that the choice is rigged. The commissioning
groups have to live within means that does not cover the costs, and are
therefore in the unenviable position of making unpalatable choices on the
behalf of the government.
The fact that we are not talking about this nationally shows
us just how ingenious the restructuring of the health service has been. These “local decisions” are dismissed as
nothing to do with the Government or the Secretary of State. Whilst they may
get some column inches in the local press they are currently remaining
invisible nationally. This needs to change!
With Stafford we have seen that the “local” bodies cannot
come to a decision, so we have the Administrator instead. Potentially they
could play the role of making the preferred solution of the community clear and
work out how to make it happen, but will they do this?
The power of the Clinical Sustainability arguement
Any policy maker who accepts the arguments for
re-configuration of the health service and who has read what the national press
& media has to say on Stafford Hospital over the last half decade could be forgiven
for believing that this was going to be pretty straightforward. Any objective
scrutiny of standards at Stafford must surely demonstrate that conditions at
Stafford Hospital, and by extension other hospitals of a similar size would be
poor, and that the people of Stafford would be only too happy to have their
services removed and have safe services from bigger and better neighbouring
hospitals. Once such a precedent has been set then of course other hospitals that
can be seen as comparable could then be lined up for downgrade too.
This may reveal the dangers of policy built as a response to
the media. The reasons why much of the press coverage of the last five years
has been quite seriously misleading is a subject for much more detailed
explanation at another time.
The 50,000 people who marched for Stafford, even those who
accept press coverage at face value, clearly do not accept that whatever
trouble there may have been seven years ago should be the basis for decisions
about the services that we need now and for the future. People who used their
vote to call for a public inquiry in 2010 did so because they expected answers
and improvement. Not because they wanted to lose services.
Standards in Stafford Now.
From 2007 when the concerns about Stafford’s supposedly high
mortality rate first surfaced the hospital has been focused on turning the
problems around. Under the three different CEOs that have been in place since
2007, and despite the obsessive interest of the media and of the regulatory
bodies (14 unannounced Care quality Commission (CQC) inspections in 9 months –
all good to excellent) the hospital has reformed. It has learned the lessons of
the Francis inquiries in the way that few other hospitals will yet have done.
Mid-Staffs is now deemed to be one of the safest 20 hospitals in the country.
The systems of governance that are in place are robust. Recruitment has been
challenging but the hospital is up to strength. On virtually all measures the
performance of the hospital is “better” than in the surrounding hospitals.
Clinical Sustainability.
So the arguments about clinical sustainability take as the
starting point that what is being offered by the hospital now is of high
quality.
The question mark over clinical sustainability is essentially
about size. These are some main factors which all apply nationally:
·
A small hospital remains vulnerable to small
changes in staffing levels. In A&E or ICU the loss of a consultant or
middle grade doctor, for holidays, sickness or changing job may tip the
department from having an adequate staffing level to one which is below optimum
levels.
·
The flow of patients in A&E is always
unpredictable, and this will be more marked in smaller hospitals.
·
There is a national shortage of Consultants and
Middle grade doctors which means that small hospitals will always struggle to
keep numbers up to strength.
·
In a small hospital the volume of cases passing
through the hospital may not be sufficient to ensure that the clinician has
experience of the problems they will see and can deal with them in the best
possible way.
·
There are some conditions where better results
are achieved by hospitals with specialist staff and equipment, and the expense
of these services means that they need to be delivered in a limited number of
sites.
·
Clinicians value the support of colleagues that
they can call upon in larger hospitals.
·
In an increasingly litigious society having
second opinions on hand is reassuring for clinicians.
·
There is a proliferation of different sub
specialisations. There are fewer and fewer generalist consultants, who are
capable of dealing with a mixture of different medical needs, and the increase
in the number of “experts” means we need larger and larger catchment areas for
hospitals to be able to support the growing numbers of specialists. This trend
is now actively under question, and there is a strong argument for reversing it
and recruiting more generalists, which would help to make the future of District
general hospitals far more secure.
Balancing Clinical and Financial sustainability. – can it be done?
The difficulty is this. Mid Staffs is now one of the safest
hospitals in the country because it has stopped doing some of the processes
that need to be delivered in specialist hospitals, it has invested in staff,
and it has invested in quality. By doing all of this Mid Staffs is now safe,
but not financially sustainable, and if it takes the measures to make it
financially sustainable then it may become clinically unsustainable.
The margins under which the NHS is currently required to
operate means that most hospitals most of the time are walking this tightrope.
When the numbers of hospitals in declared financial or
clinical difficulties began to rise into double figures I felt we had to try
and understand the reasons for this.
·
The tariffs are set to deter acute admissions
and to encourage integration.
·
It is only possible to make the tariffs work by
radical change of the way the health service is delivered.
·
Integration is the right direction of travel but
is not in place.
·
Making Integration work means improving
communication between organisations.
·
It could take ten years to get this right.
The aspiration of Integration.
When you study the transcripts of what when wrong in Mid Staffs
the matter is pretty clear. When staffing cuts and bed cuts were carried out in
Stafford, at the same time as cuts in Community care was happening then there
was a build-up of patients in Stafford Hospital, who probably should not have
been there in the first place and could not be discharged. The expensive care
that they needed was not met by the tariff system that was designed to prevent
such admissions. With squeezed budgets the costs did not meet the care needs. Care
suffered.
The reports coming out of Stafford, and others from age
concern, the Kings fund, the Alzheimer’s society, and the ombudsman all pointed
in one direction. It is important to find better alternatives to acute care
beds for frail elderly people. It is important to find ways to make primary,
secondary and community care work effectively together.
Everyone accepts the need for the integration of services,
but most people are concerned that the cuts to acute care are being carried out
before the necessary preventative and re-enablement care is in place. It
appears that the right thing is being done in the wrong order.
The Stafford Blue Print.
The recommendation to the administrators was to downgrade
Stafford to the status of a “local hospital” which would offer no acute
services. This is not acceptable to the 50,000 people who marched on 20th
April.
The Administrators have indicated that the recommendations
were based on the remit that the Contingency planning team were set, looking at
Mid Staffs in isolation. The administrators are not bound by this, and are now
looking at solutions which fit the needs of the wider health economy. This
means looking at the demands and capacity of the neighbouring hospitals and
suggests the creation of a networked solution.
There is currently active consideration of the amalgamation
of Stafford and UNHS to create a hospital where the size will give economies of
scale, and which could relieve some of the capacity problems currently being
experienced at UNHS. The plan preferred by the community would mean keeping a
level of A&E, ICU, Acute care and maternity at Stafford.
It needs to be considered that amalgamating Stafford and
Stoke would bring together two trusts, each with their own financial
challenges. Whilst amalgamation would bring about some economies of scale it
should not be assumed that this will be adequate in the longer term.
Building sustainability means investment in making
integration work. Initially double funding may be necessary in order to make
this happen.
We have been used in Stafford to being seen as the “NHS
problem”. In Stafford we would prefer that it should be seen as an opportunity.
Stafford can be the testing ground, to build a blue print for the future for
district general hospitals.
The 50,000 that marched in support of Stafford hospital are
an asset. They are people who understand a lot about the pressures on our
health service. They take a realistic view, and if invited to do so will assist
with the design of a health service that works for the future. It would be
crazy not to make good use of this extraordinary resource.
It’s your turn next.
Just remember, whatever happens here is Stafford has
implications for people all over the country. The changes that are happening,
driven by the accountants in the Treasury, the DoH, Monitor, Hospital Board
rooms, Health scrutiny committees, The Management consultants and the CCGs are
bringing change to your health service. If you live in a small town like
Stafford your hospital services may be obviously threatened. If you live in a
community with a large hospital the threat will be less obvious, but the change
is happening whether you see it or not.
Many people will watch from the side lines to see what
happens. In Stafford we know that the Support Stafford Hospital Campaign is
being fought on behalf of the whole NHS. You can help us by pressing for open
debate on “sustainability” and what it means for your services.
