Lewisham A&E under threat – a danger to all SE London

1. There is also Darrenth Hospital in Dartford that has taken a big chunk of Bexley residents too.

   That said it’s not encouraging to hear of yet another facility going. People are getting further and further away from health care. Perhaps it’s just me but as the population grows it seem counter intuitive to close facilities.

2. As a supporter of the NHS, I am surprised that you think that in London we need as many A&E facilities as you suggest. Actually the most important thing is that the A&E is an acceptable distance away and the clinicians that are there have sufficient experience (which includes throughput for some particular conditions) that they provide the best possible service. This was the reason stroke and trauma services were rationalised at more specialist A&E facilities (e.g. King’s) a few years ago. Likewise, Lewisham Hospital will be a great Urgent Care Centre (still seeing about 85% of the types of patients it does now) and will have its future secured by becoming SE London’s centre for elective care. Sounds a good thing to me! Please don’t think that having a local hospital gives best care, what we need to remember is that care needs to be appropriate for the setting and clinically safe. That is what this report looks at – as well, of course, at finding a way through the PFI silliness that was imposed on the NHS previously. I won’t be marching – I think this report will save and enhance Lewisham Hospital, and provide a great future for the Queen Elizabeth in Woolwich which will come under Lewisham’s management. I urge people to read the report …

3. It’s a funny issue, isn’t it … As I understand it, you get the best clinical outcomes – whether that’s for A&E, for cardiac care, for knee surgery, for any other specialism – by concentrating services in a relatively small number of centres, where the clinicians can develop their expertise and are each seeing enough cases to stay current with new developments.

   Obviously for A&E, if all other elements are equal, a 5 minute ambulance journey is better than one that’s 15 or 25 minutes. But if that 5 mins is to a smaller unit, against 20 to a bigger, more practised one?* No-one gets any votes trying to explore that nuance and arguing for a local hospital to lose its A&E – it’s always seen as downgrading services.

   I agree with RG – it’s worth reading the report. It’s very careful in its language, but basically outlines the impact of at least eight years of less-than-wholly-successful reviews, reforms and reorganisations.

   Importantly for the finances of the trusts in the future, it also suggests that the current debt – expected to be £207m by March next year – should be written off by the Dept of Health, and that the DoH should commit to annual payments (initially of about £23m) to meet the excess costs of the ongoing PFI contracts. (This is about a third of the actual PFI costs – I assume that the ‘excess’ is the fact that they make up 16% of the trust’s current spending, as opposed to the 10% that’s the average for other trusts.) At least there’s a formal acknowledgement that the PFI contracts for QEH and the PRUH ‘cost the Trust substantially more per year than had they be financed through traditional public financing arrangements.’

   [* In fact, the report says the travel impact of the proposed changes would be little more than an extra minute’s journey time for someone under blue lights.

4. Thank you for highlighting the issues facing residents of South East London following the draft report in respect of Health provision being suggested by the Administrator Matthew Kershaw. It is important that sufficient time is taken to study the report in detail,listen to the views of residents and continue to discuss the key proposals with the key stakeholders. Additional public meetings in Woolwich and Eltham are planned and everyone will be able to contribute to this important debate. This important report follows the decision of Andrew Landsley to abandon the Picture of Health proposals which was designed to resolve the deficit over time. This was abandoned following representations by Bexley Members of Parliament. The consequences has added to the deficit over time.

   The PFI set up by a former Conservative Government and signed off by a Labour Administrator was not our finest hour. The staggering debt should and must be resolved and lessons about future public sector capital spending needs to be learned. Services and jobs are under threat and serious thought about future health must be given. It is important that the health needs of residents remain a priority. However this report needs to be looked at alongside the proposed changes to Community provision provided by GPs under the Clinical Commissioning proposals. I would encourage residents to get involved in the debate,read the report and engage in the public meetings. It is our Health Service after all.

5. Some interesting points here. Specialist services are indeed better provided at centres where experience of these conditions is high, centres for Heart Attacks, Strokes and Trauma all fit this bill. Emergency Department services however are not specialist, they are high volume and wide variety.

   The problem being overlooked in these proposals is one of capacity. The current system is unable to cope, reducing its capacity will have pretty obvious results. If you doubt this then pop down to either one of these two units and see for yourself!

   Co-located Urgent Care centres give an artificial picture of capacity, people go to Lewisham for the ED but are streamed to Urgent Care bacause it is appropriate for them, take away the ED and they will not take the chance, they’ll go to QE! This is exactly what happened with the Urgent Care at Queen Mary’s Sidcup, its staggering that no one has learnt lessons from that error.

   Queen Elizabeth is the problem, it is a terribly managed and poorly staffed unit (the two do go hand in hand I’m afraid) but action won’t be taken to address that because the PFI conditions are too expensive.

   Finally please don’t ever suggest that ambulance journeys on blue lights will only take an extra minute, its completely untrue and repeating it just attempts to give it authenticity.

6. John is quite right about larger, specialist units delivering better outcomes. This is not some Whitehall spin, it has been proved over several years in the UK and elsewhere.

   In Germany [or maybe it is NL, can’t put my hands on the info just now] the specialist units have live AV links with paramedics in the ambulances – and in some hospitals emergency team members are assigned specifically to this role. Anything that ensures specialist care can start before the wheels start to turn – thus starting treatment earlier in the golden hour – has to be a plus.

7. It frustrates me to see people attempt to justify the plans on a clinical level. These plans are nothing to do with improving patient care, they are merely an exercise in pushing the failing South London Healthcare trust towards financial viability.

   Lewisham Hospital is well run (both financially and clinically), has recently benefitted from significant investment, and is fundamentally better located to provide an A&E department and other emergency care than QEH.

   People /will/ die unnecessarily if these proposals are carried through.

8. As the other commenters have said, this set of documents is very detailed and is not a straight “headbanger let’s destroy the NHS” approach. However I think that the suggested outcome is very unfair on Lewisham Hospital – yes they say that 80%+ of A&E traffic remains unaffected but that is supposition – and the new maternity investment may well be wasted as well (this is up for discussion). As you say Lewisham are v angry, as should we be in Greenwich (as you rightly say) – those on the west of the borough use Lewisham a lot. I have commented here http://greenwichlib.wordpress.com/2012/11/05/fireworks-likely-over-lewisham-hospital-proposals/

   Good to see Cllr Fahey’s remarks – as ever he is one of the few that engages. He is also gracious enough to admit that the quite outrageous PFI contract (signed under a Labour Govt) is at the root of this Trusts problems. The subsequent management of the Trust also leaves a lot to be desired as the report makes clear.

   Lastly – there has been a lot of work done in Canada on trauma centres i.e the trade off between ambulance journey time and the expertise of the centre once you arrive. The evidence is compelling in favour of by-passing local hospitals in order to improve survival rates. On the other hand a large metropolitan centre like London is not British Columbia… this issue is going to be a big hot potato in the UK methinks.

9. the ultimate lesson should be that no politician should ever again be able to claim that PFI is anything other than a tool to have our cake now (and hopefully get said politician re-elected), and let future generations pay (expensively) for it later…

10. We have a fiscal situation which is worse than Spain’s. Get used to lots more of this unless someone can find a magic money tree. This is what happens when you let Labour loose for 13 years. If any politician tells you that there is another way tell them to read “This Time Its Different”.

11. Richard needs to have a clearer understanding of the differences between the UK and Spain. Bankers in the UK get richer while the poor get poorer. Clearly he forgot about the debt in the UK increasing rather than decreasing.

12. Fahy, I really suggest you read the book. I would also look up “pro cyclical fiscal policy” while you are at it. Have you any idea how much the CEO of Santander makes a year? Maybe you would also like to offer some insight into the fact that the government are ‘cutting’ at a slower rate than the Labour party committed to in their last budget and manifesto. Labour spent 13 years destroying the public finances of this country so we are now in the situation where our debt/gdp and our deficit/GDP are among the very worst in a highly indebted World. More hospitals will close, taxes will rise, growth will be slow. Thanks Gordon and Tony.

13. Mike has it bang on.

14. Fahy,
    I wouldn’t normally comment on this, except in this case facts suggest Richard is right, and his comment is far more important than you give it credit.
    UK deficit this year is forecast to be 8.4%, worse than Spain’s 6.7% (source http://www.economist.com/news/economic-and-financial-indicators/21565640-trade-exchange-rates-budget-balances-and-interest-rates). UK 2012 debt to GDP is 89% compared to Spain’s 91% (source IMF WEO), but the UK figure misses out masses of PFI debt as well as huge contingent liabilities from the nationalised banks. And yes, both are rising, and the deficit is close to being out of control, hence his point.
    We are just going to have to get used to the idea that we have (all) lived beyond our means and there will have to be belt tightening. Politicians need to be more honest with us on this, but as Jean-Claude Juncker has said, “We all know what to do, we just don’t know how to get re-elected after we’ve done it.”
    You might also want to have a look at chart 8.1 at http://www.hm-treasury.gov.uk/budget2012_distributional_analysis.htm. It’s the wealthy that are disproportionately paying now (although agreed they can afford to).
    As for your cheap anti-banker shot: WHICH bankers get richer? The 25% of the ones who worked in the city that have lost their jobs? WHICH bankers do you blame for the crisis? The ones behind the counter at NatWest? The ones who gave you your credit card? The ones who work for banks that were never bailed out? The ones who worked for foreign banks that never cost the UK taxpayer a penny? The real story is much more complicated. Are ALL councillors corrupt?

15. Shouldn’t A&Es be relatively easily available for those who don’t actually need an ambulance to get them there as well as those who do? Just wondered. And the concerted barrage of facts and figures from the few in favour of this reduction in local services would be impressive if it weren’t for poor old Niall giving himself away in his last line of his gradually redder and redder faced post. Must try harder next time, chaps.

16. Wolfe: of course ideally we should have A&E’s close to everyone. But you are missing the big, big point: we don’t have the money. Ideally I would go on expensive holidays once a month, but I don’t have the money, and I don’t want to get into debt to finance it either. The government (i.e. us) is in exactly the same position, but with more debt than me. We had all better get used to cuts.
    PS I haven’t read the report so I haven’t got a view on whether the proposed changes are good or not. But I am a professional economist, so I do have a view on the economy, and we need cuts, whether we like them or not.

17. Of course we have the money. We’re spending billions on replacing Trident nuclear missiles, aren’t we?

18. The NHS is free at the point of use so demand will be infinite. There will always be caps of the level of service provided as we do not have unlimited amounts of money. Vested interests always seem to use scare tactics when any debate about reorganising NHS provision comes up. Basically change anything about the NHS and you will die. The debate is never really about the actual clinical evidence. I dont know if this is a decent solution to the current problem but if it is not then money will have to found from elsewhere and the whole non debate will come around again. Maybe we could take the money from doctors’ pension pots (that they have not paid for) but we all know how that would end.

19. QEH was always a big mistake, and it’s failing. There’s a military dictum that goes ‘never reinforce failure’ – but by closing Lewisham’s A&E in favour of QEH, that’s exactly what the DoH are doing. Sure, free healthcare must be rationed, but let’s have a rational debate about what the priorities are; IVF, cosmetic procedures, expensive treatment for long term chronic but not life-threatening conditions must surely be lower priorities than blue-light medicine – actually keeping folk alive today.

    The time’s coming when some harsh and painful decisions must be made. Rationing decisions are always tough. Children with special needs or hip replacements? Respite care or horse riding for the disabled? Silicone breasts for the disadvantaged or physio for stroke victims? We’re reaching the stage at which we have to admit that the scale of the post-war Welfare State is no longer sustainable, in any western democracy. At the same time the pressures from external ‘free riders’ to access welfare service will be greater than ever – and this is a two-way street. The sharp-elbowed and articulate will have their triple bypasses and vein-stripping done in French or German hospitals, as long as those nations’ money lasts, just as the pressure on our maternity services from our own visitors demands domestic resources.

    If we allow the whole thing to degenerate into squabbling competition for scare resources the losers will always be the poor, the inarticulate and the incapable. When Beveridge went to war on ‘squalor, disease, ignorance, idleness and want’ folk were dying of TB, typhus, diptheria and cholera and dying shortly after retiring. We may actually have to not only concentrate resources on those old foes we thought long vanquished, but see a reversal in yesterday’s ever-increasing life-expectancy. May the Good Lord guide all those in political office, for they are facing decisions of a consequence few can have ever experienced.
    .

20. Niall, I understand your stance but I disagree. Firstly, as Darryl points out, we do have the money but choose to spend it elsewhere – economics is, among other matters, about the distribution of money. We could choose to distribute it differently. It’s also about theory and interpretation. Keynes and Hayek would be as unlikely to agree about economics as Hobsbawm and Corelli Barnett on interpretation of history, or drummers on the right way up to hold the snare stick. Saying ‘I’m a professional economist’ just makes you someone with an opinion. The debate, in my view, IS about clinical evidence. People will, more than likely, not receive better healthcare if A&E access is restricted in this way. It’s also about how we want our society to approach healthcare because, Armitage, Beveridge’s five giant evils do still exist, and we have to decide whether we think we should continue trying to eradicate them or only do that if the books balance in that particular part of our economy instead of reducing spending elsewhere – yes, on huge, and basically useless, items like Trident, that we’ll never use but make us feel like big men.

21. We don’t have the money! We are currently borrowing over 8% of GDP a year: roughly the cost of the entire NHS.
    I hate Trident. I really do. But the costs are around £25bn spread over 30 years and thereafter £1.5bn a year (Wikipedia). The NHS costs roughly £100bn. Per year. So scrapping Trident will finance around 2-3% of the NHS: nowhere near enough I’m afraid, even though it would be a great idea. So we are going to either have to cut costs or increase taxes, or some combination of the two. “Distribution of money” is another way of saying cuts somewhere. Where are we going to find 8% of GDP/c£100bn?
    Agreed, economists have opinions, but they at least back them up with facts.

22. Lets not kid ourselves either, the cost of healthcare provision is going to increase during the next twenty years accross the Western World as the baby boomers retire. They have promised themselves free healthcare and pension payouts that they have not paid for. Provision will have to restricted or funded via increased taxes on the young. Given the electoral size of this cohort I would imagine politicians will be loathe to actually ask the boomers (who are the wealthiest cohort ever to live) to put their hands into their pockets and pick up some of the bill. We are witnessing a huge inter-temporal transfer of wealth from the young to the old. Huge problems await..

23. No surprise to see to the Tory right wing propaganda machine at work here.

    How long before they start attacking the lazy / malingering disabled.

24. Dave you could always use a few facts in your argument than just dismiss an alternative argument as propaganda. I dont think anyone has said that closing Lewisham A&E is a good idea per se rather that if it is to remain open then cuts will have to fall in other places. The Labour party acknowledged this, indeed their projected cuts (if you calculate a cyclically adjusted primary deficit) as laid out in Darling’s last budget and the menifesto were more severe than the current government’s fiscal stance. To argue that simply by cancelling Trident would make any difference to how the rest of our public services are funded does not stand up to scrutiny.

    Hey it would be a lot easier to blame the bankers but the real World is a more complicated place.

25. It is easy to blame the bankers, who are now beginning to make Trident look cheap.

    Bottom line is QEH is failing, Lewisham is well run. Who in their right mind would think that closing the good hosptial and then asking its managers to try and revive the failed one is a good idea.

    Surely this is the definition of throwing good money after bad.

    Pay off the PFI and close QEH, that way you save money and lives!

26. I can’t say I’ve been up to QEH recently but I did spend rather too much time there last summer.

    One of the things that amazed me at the time was the use of portacabins as overflow for the A&E department after the closure of Queen Mary’s. Things may have changed since, but if the hospital couldn’t cope then, how can it possibly cope with covering for another 200k people?

27. I’ve skimmed over the posts above, some interesting points. Got to say though – people are frequently being turned away from the QE A&E because it can’t cope with the demand currently on it. It’s all well and good suggesting that big centres work better than local provision in some cases but if the big centre can’t cope with demand then it’s silly to think that closing one of the A&Es it diverts patients to can close without having a negative outcome. DVH and the PRUH will also be affected as more patients will be diverted to them if Lewisham isn’t option.

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