Friday, 2 August 2013

Watch out for the baby in the bath water!

After a first full day of reading my way into the TSA recommendations for Mid Staffs my thoughts are getting clearer. The report is very largely about money.

This is a small trust. Small trusts struggle financially. It is pointed out to us that it would be unfair to expect the other neighbouring trusts, many of whom are also struggling, to bail us out, in the way that we did for them in 2006. The extraordinary pressures on Mid Staffs over the last five years have added greatly to the costs of running the service here. The task that the TSA had to do was to find a way to make the service in the key word of the report “sustainable”.

It seems that the way in which the TSA have approached this task is essentially to start with a blank piece of paper. What are the services that must be offered, who is willing to provide them, how would that impact on other neighbouring hospitals. Their recommendations are built on this.

Let me first say I welcome the proposals to link Stafford and Stoke, because I believe that this does deal with the “small hospital” issue, and will mean that it is easier and cheaper to attract the staff that we need, and that by allowing staff to work at both hospitals it ensures that skills are maintained. This addresses the issue of making the service “clinically sustainable”.

I also welcome the proposals to bring more elective procedures back to Stafford, which gives a better financial basis for the hospital to go forward. It is the loss of the elective processes, on top of all the other pressures over the last few years that made Stafford “financially unsustainable”.

As Jeremy Lefroy has been pointing out regularly in parliament, the Tariff system for Acute and emergency medicine, which was put in place in 2009 with the idea of focusing more spending on prevention, means that acute medicine is being run at a loss, which largely explains the national crisis in A&Es. This needs to be addressed nationally as a matter of urgency.

I also cautiously welcome the development of assessment units for the Frail Elderly and for Paediatrics, though the way in which this is done will be important.   

What shocked me was the realisation that the TSA when they threw out bath water do not seem to have seen the baby.

We are asked to be thankful that A&E is to “remain as it is” and yes indeed it is a good thing that there will be a consultant led A&E if only for 14 hours a day. This is a decision that the TSA will have seen was inevitable, in part because of the strength of public feeling, but also because when they look at the emergency medicine networks in the region and read the incredibly strong representation from the neighbouring A&E leads that it is very clear that you cannot run this system without an A&E at Stafford.

The “remain as it is” leads us to the question – But Is it? The answer is “No”. Our A&E is currently supported by a level 3 Intensive care unit, which is able to deal with a given level of critically ill patients. If they downgrade this to Level 2, which is proposed, then this will mean that ambulances that currently stop at Stafford will for a number of patients carry on to Stoke. The effect of this experiment would only be discovered over time. We have been hearing for some time that there would be a new creation a level 2.5. It appears that this means that the ICU would deal with level 2 patients in house but with anything more serious they would “stabilise” and ambulance them off to where ever a level 3 intensive care bed could be found.

The ICU network that supports our health system is over stretched. There are not enough ICU beds. When there is a critically ill patient there can be frantic phone calls to find a bed, which can be at a considerable distance. There was the recent tragedy of a lady who finally ended up dying in Hereford some months back.  The distances are a problem, not only for the patients, but for the efficient management of staffing. When I asked the question the staff patiently explained to me that transferring a patient to another ICU ties up a doctor and a nurse to travel with them and to then travel back. In the hours this takes their skills are lost to the hospital.

The advice the hospital working group has been given by the Royal college of physicians is that having a level 3 ICU is central to the hospital being able to offer the services that we as the public wish from it.  With ICU level 3 then the hospital can deal with the majority of cases excluding Stroke and Trauma which already go elsewhere. Without it then the level of treatments will be limited, and Maternity and Paediatrics and any acute surgery become impossible.

A key part of the argument for the next few months will be about the level of critical care. How much would it take to give us back a Level 3 ICU? Is there a major cost implication in going from a level 2.5 to a level 3? Should as Jeremy Lefroy suggests the cost of a level 3 be met nationally as part of a national network of scarce Critical care beds?

Which brings us to the baby.

What did shock me last week is a visit to Maternity and Paediatrics, which showed me that some of the assumptions I had made about the way the TSA would carry out their work were wrong. I had assumed that the starting point for their task would have been to visit the different departments in the hospital and to develop an understanding of what people were doing and why, and find out what we already have here that is valuable.

It was clear to me as I listened to the people from Maternity and the Paediatric departments the immense pride that they have in their work, and the way in which the Paediatric service in particular has developed over the years to meet the particular needs of this community. The service may be unique, It is certainly valuable. The TSA do not currently know this, because they have had no discussion with these departments.

The future of medicine needs to be in the development of integrated care, linking primary, secondary and community care, and working with the wider community to prevent illness and support ill people. District general hospitals are perhaps the best placed organisations to be able to deliver this. The Paediatric service we have in Stafford does just this, and the TSA that are downgrading the service do not know, because they have not looked.

The TSA have come to this task armed with reports from the Royal colleges to support their decisions to centralise care in bigger hospitals. I know that there are many strong arguments against this. Are there enough people speaking out to make the case for the District General Hospitals of the future?

For me Stafford is not just about Stafford, it is about the future of the NHS and the future of the District General Hospital. We need the help of others who care about this to come to our aid now.

I do not know what the next few months will bring, but I hope that this period of consultation can bring us all a better understanding of the kind of service we need for the future, and the way we can build on valuable local knowledge to give us that.

If we go back to the Academy of royal medical colleges report they are very clear that reconfiguration of the health service can only be done successfully with the support of the community, and that the pressure that TSAs have to work under are not an ideal starting point to achieve that. I hope that that TSA will go into the consultation process prepared to listen, prepared to understand more, and prepared to help this community achieve the outcomes that it deserves.

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