II DISCUSSION
Comments and opinions recorded here – except for
CHAIRMAN’S REMARKS - are not to be attributed to any
particular person present at the meeting, and they do not represent the
views of any particular organisation, voluntary or statutory. (See "Chatham
House rules".) Comments made outside the meeting, in
communications to the chairman, were included in what was said at the
meeting.
[The meeting had before it adapted
sections from the
Eastbourne Forum for Older People website NEWSPAGE on the
"Fit for the Future" proposals and options, including
letters/messages from Claire Lee on behalf of Sylvia Tidy,
Chairman of the East Sussex Health Overview and Scrutiny
Committee; Nick Yeo, Chief Executive of the PCTs; and David Townsley, Director of Finance, ESHT. These letters and
messages are also available on the Forum website.]
II.1
The scope and responsibilities of
East Sussex HOSC were explained.
HOSC is comprised of
councillors, both from East Sussex County Council and the
districts and boroughs. It included two voluntary organisation
representatives. HOSC is charged with taking an interest in NHS service delivery and to investigate the choices and
results. It sees itself as the defender of the public in East
Sussex. It is asking, what reasons are being given for the
proposed NHS changes?
HOSC has yet to see any
evidence that any one of the Four Maternity Options is
acceptable. HOSC will ask what
will be the point of "consultation" if the overwhelming
response is one of rejection of the proposals being presented,
unless there is a decision to reject those proposals.
II.2
There is direct reference to older
people’s services in the PCTs'
Fit
for the Future Consultation Document's proposals for emergency services.
Concern was expressed that there may be an impact on surgery
generally
if night-time surgical cover is withdrawn from one of the two
hospital sites (EDGH or the Conquest). The proposal had not
specified whether this might be done permanently or by
swapping between hospitals even on a daily basis. There was an
increasing potential for a lower quality of care and for
error. An "A&E presence" at both hospitals is the expression
used by the Chief Executive. It is felt that A&E will not stay as it
is but there is no guidance as to what it might become. Satellite
centres might be provided for non-emergency medical services,
taking pressure off A&E but these had not been proposed.
Few would object to an "A&E
presence" providing satellite centres/facilities (for between
25,000 and 35,000) are established beforehand.
II.3a
The web-published PCT costings
for Options 1-4 - as against a costing for "status quo", which is stated
not to be an option. (No-one
is supporting the "status quo", and it is misleading for the
PCTs to constantly refer to it even obliquely.)
The figures behind the bottom-line option costings are set out in more detail in documents
released to HOSC, and reveal the assumptions behind them. These
assumptions are contestable and if varied, even marginally, give different
end-results. A more sophisticated statistical presentation
would give variable parameters for significant assumptions and
the effect on the bottom line for each option could be
illustrated, let alone computed at the click of a key. The
costs are the provider’s costs, not commissioners’ costs.
(This becomes important if throughput ("business", or
"results") increases or decreases as a result of
changes – see
II.5 below.) There continues
to be no published equivalent costing for the campaigners’
Option 5. HOSC and others had been assured that all options
including Option 5 would be costed on the same basis and
consulted on at the same time. If Option 5 is costed late in
the day, albeit by an independent panel, what consultation
will there have been across all the options?
Known options on maternity
(1,2,3,4 and 5) should be calculated on in exactly the same
way and by the same people. To do otherwise is to present
an unbalanced perception.
II.3b
ESHT and the PCTs have not published indicative or provisional
income and budgets for 2008/09 –
however tentative – against which to gauge the costings for
options, so that how affordable the various options are could
be judged. How can the PCT Boards reach an equitable decision
in the absence of budgetary implications; how can HOSC make a
recommendation to the PCT or the Secretary of State in their
absence? How can
decisions be taken in the absence of contemporary decisions –
or even
proposals and consultation – in bordering hospital trust areas?
II.4
But why should a decision on
maternity
services – and to a lesser degree one aspect of emergency
services – be prioritised over all other PCT-commissioned
medical services, determined first and then the rest of the
services be funded from the remaining income? The CHAIRMAN'S
REMARKS
refer to this as
"potential implications, consequences or knock-on effects...
on other services". Some fear that once
the decision on maternity services is taken, there will be a
successive domino effect over time e.g. on paediatrics, on A&E, on
anaesthetics and surgery. Immediate – say 2008/09 - "costs to
other services" are separable from "a domino effect" but only
in the short term. Nor are hospital costs to the PCTs separable from
what they will be able to make available to GP services. A gulf seems to
have widened between the PCTs’ belief that not everything can
or need be considered together – though the Chief Executive
says that each decision is taken "holistically" – and
those who believe
that more could and should have been considered at this
juncture, which had seemed to be the PCTs intention until the
Consultation Document was issued. It remains HOSC’s responsibility to take up
any matter that implies significant service change. It is
hoped that this can be done in a timely manner, not when it is too late.
II.5
If there is a loss of
confidence in the services provided by ESHT, people may
exercise patient choice
to go to other hospitals to a greater extent than presently occurs,
and the East Sussex PCTs will pay for that, while ESHT loses
income. While business
taken elsewhere has to an extent been factored into the
published costings, it has not been based on flight from ESHT. If it occurs, what then for the determination that ESHT
maintain two viable hospitals in Eastbourne and Hastings into the
future? (And of what kind?) The implications of such "business" variables would be noticeable in a more
sophisticated statistical presentation of costings. They could,
if decisions create more confidence in ESHT, result in
movement from Kent, Brighton, West Sussex
and Surrey PCT areas to increase income to ESHT, at
no cost to the PCTs. Why not go for this, especially if East
Sussex is indeed first in the field in "Fit for the Future"
decisions.
II.6
The only argument that the PCTs
appear currently to fall
back on is that the Boards will reach their decision on
maternity services at ESHT wholly on clinical advice –
local? national? - regardless of comparative cost. This
seems not to fit in with everything else about the NHS, for
example the ability to afford new drugs and treatments. But HOSC seems so far to be of the opinion that the decisions will
be taken on a financial rather than a clinical basis, though
the PCTs deny this. There was a clear conflict of opinion.
Even if a decision could be taken about maternity services
without reference to cost, why should all other services then
queue for stringent commissioning requirements (“value for
money”).
II.7
HOSC might like to see a
view taken over a 20-25 year period; the PCTs and ESHT seem
not only to work a year at a time but to set themselves
against thinking beyond that, as a kind of impossibility –
three years seems an eternity to them.
The NHS is a service a not a
business. While business methods should be introduced to be as
effective and as efficient as possible, a balanced business
sheet at the end of a day, year or even decade
shouldn't be required. Concern was
expressed that the NHS treat patients as people and think of care not
performance. "Payment by results" is an ominous
formulation. While all agree that health and safety are
paramount, some believe that there is evidence to show that these
are higher with one base even if there are longer journey times.
But the
Consultative Document should have not have estimated journey
times
only at off-peak times
(being said to have been
calculated at 0600 hrs).
Journeys from postal code to hospital destination of normally
30 minutes or longer are known to be dangerous to patients and
stressful for ambulance personnel. How many of those are
there in the off-peak journey times and how many would there
be at peak times?
II.8
ESHT intends to apply for
NHS foundation trust status – as one hospital - on which the
PCTs will work closely with the hospital. The Department of
Health’s permission is required for it to apply. (See
http://tinyurl.com/2wngkl.) What difference would that
status make? Would it be more free of the PCTs and therefore
more able (and willing) to respond to public opinion,
adjusting to what local people want? (Or could it respond
less?) The application would go out to public consultation but
the meeting remained unclear as to when – only after the DoH’s
permission to apply - and how. Would ESHT’s notion of
consultation be the same as that of the PCTs’ limited and
flawed process in respect of the present proposals and
options? How would ESHT engage the public, where the
PCTs, with their consultation, had failed to do so, so far
isolating itself from its public? The present consultation
perhaps offers a warning that there is more to public
engagement than public consultation.