Friends of Eastbourne Hospitals’ full statement re: NHS changes

The Friends of Eastbourne Hospitals have spoken out against controversial plans to centralise three key services at either the DGH or in Hastings.

The 3,000 strong group, which has raised millions of pounds for the DGH, sent this letter to the Herald explained its decision:

Public Consultation – “Shaping our Future”

The Friends of the Eastbourne Hospitals is a registered charity, whose aims and objectives are to “support the Eastbourne Hospitals”. It is an independent body and plays no part in the management of the Hospital Services, and whilst working closely with the East Sussex Hospitals Trust, it is not responsible to them. It is also independent of any of the campaign groups. The Trustees are responsible to the Charity Commission for the performance of the charity and are subject to election and re-election by its membership at the Annual General Meeting. It has nearly 3000 members and whilst it avoids becoming drawn into hospital management issues, that membership will expect the Trustees to form a view on matters under consideration during this public consultation. The Trustees have, therefore, considered at length the proposals put forward in the document “Shaping our Future”.

We find the document not only to be misleading, but also inaccurate. These are very significant and serious proposals that will have far reaching and long standing consequences not only for the specialties under consideration but, potentially, for the whole of the Hospital Services. They need to be very carefully considered.

General observations:

The document tries to scotch the “myth” that this is all about finance. However, it is well known that the Trust has to identify significant savings in order to meet its financial targets. At the beginning of the strategic review, we were informed that the current methods of working were inefficient and rationalisation of services was implied. Financial figures are glossed over, but it is inconceivable that the Trust has not done detailed financial work on any of the proposals. They would not have been put forward unless savings could be made.

The document claims that these changes are broadly supported by the Hospital Consultants and G.Ps. However, a leaked letter from the Eastbourne Hospital Consultants indicates the opposite. It is also noted that the GP prominently quoted in the document has his practice in Seaford where the option for referral to Brighton is already a strong alternative.

The document claims that no decision has been made on the single site should it go ahead. Indeed it would be foolish to announce, ahead of the consultation, that “Town A” was the preferred site since all of “Town B” would immediately be opposed! Again, it is inconceivable that the Trust will not have carried out detailed financial studies and has a preferred option. During discussions, local Consultants lapse into saying “when” services move to the Conquest rather than “if”. In addition, informal discussions with nursing staff indicate a general assumption along the same lines.

A number of figures and statistics are quoted in the document. These are misleading and inconsistent:

A headline figure of “only” 3850 affected patients is quoted – yet addition of the numbers identified in each of the specialties adds up to 4513!

On one page (orthopaedics) two different figures are quoted for the same group of patients.

Mistakes that call into question the accuracy of others.

Statistically, the Trust makes a number of claims, principally that it is a very small number of patients that will be affected. To do this, the Trust includes 310,000 out-patient appointments and 120,000 emergency department patients – this will distort all of the statistics. However in the case of General Surgery it rises to 40% of all cases (including day case surgery) and climbs to 76% of inpatient General Surgery patients. In Orthopaedic Surgery it is 25% of all cases, climbing to 46% of inpatient Orthopaedic patients. These are not insignificant figures.

In all three specialties the Trust states that improvements in community care are required to provide on-going support for patients. We support this, but these improvements can and should take place whatever the outcome of this consultation and should not be made dependent on single-siting.

The document contains three case studies to indicate a) what happens now (not good) and b) what will happen in the future if these changes take place (good).

“Elsie’s case” describes what happens to an elderly patient with a fractured neck of femur. We know that this has caused great resentment amongst the orthopaedic surgeons in Eastbourne since the future model of care is already the model adopted in Eastbourne. This is not only misleading but a distortion of what actually happens and calls into question the accuracy of other statements in the document.

The document states that if a patient arrives at the hospital that does not have the specialist centre they will quickly be assessed by a specialist doctor. However, out of hours, this specialist will not be a Consultant whereas this will always be possible at the other hospital.

Stroke Services: We note that the Trust believes that by concentrating services on a single site it will be easier to appoint a “Stroke Physician”, and in this respect we agree with them. However, since this Stroke Physician cannot be available 24hrs a day, 7 days a week, this will not alter the fact that out of hours i.e. evening, overnight and at weekends, admissions will still be under the care of other Consultant Physicians, as they are now.

We note that the Trust intends to use telemedicine to assist with patients arriving at the non-specialist hospital. We believe that this could be used to improve stroke services without the need to single-site them.

We also note that patients are currently admitted to identified areas of existing medical wards. These can be transformed into Stroke Units and be appropriately staffed. With training, the staff can develop the necessary specialist skills, with any shortfall corrected by use of the telemedicine facility.

We note that one of the reasons for single-siting is that patients could be fast-tracked to the Stroke Ward and gain access to CT at an early stage. One of the reasons cited for delay is lack of available CT time. This will be overcome by the installation of further CT machines – but since this is currently planned for both sites, should not be a reason for single-siting.

We welcome the decision to improve community rehabilitation services closer to the patient’s home. However, these changes can take place without the need to single-site the specialty. We note that the Trust intends to do this by increasing the bed provision at the Irvine Unit in Bexhill. Whilst, technically, this is closer to home for Eastbourne residents if the single inpatient unit is in Hastings, it is not what the general public will regard as being close to home! We ask the Trust, therefore, to develop such facilities at a site within the immediate Eastbourne Area.

We are conscious of the fact that many stroke victims are elderly and that their closest relatives and friends are similarly aged. Taken out of their home environment, a significant number of elderly patients may become confused – a confusion that will be compounded if their close relatives and friends find difficulty in visiting them. Road access between the two towns is not easy and can be extremely busy along a road that has been recognised as one of the most dangerous in the country, whilst public transport is both more time consuming and in most cases requires at least one change. Visiting is very important to any patient and not only adds to the patient’s well-being, but visitors frequently perform little services for the patients that may otherwise be overlooked. (A view supported by many nursing staff).

General Surgery: We are not convinced by the arguments put forward for the centralisation of emergency and high risk General Surgery. Whilst it may solve the problems of the on-call rota, we believe that it will create many further problems.

Emphasis is placed on the fact that centralisation will provide better access to specialist surgeons. However, out of hours, that access will remain as limited as it is now as each surgeon takes part in the on-call rota. At present, unless a patient requires surgery that cannot wait overnight or over the week-end, the opinion can be sought the following “working” day. This will not change – if necessary, that patient can be transferred to another hospital, as happens for those rarer conditions requiring transfer now. Whilst this may not be ideal, there would be many fewer patients subject to transfer.

We believe the argument that centralising services will generate more experience to be flawed. Assuming no reduction in Consultant numbers and that referral patterns remain the same, then the same number of Consultants will see the same number of patients. Referral patterns will, however, almost certainly change. Patients to the West of Eastbourne, including the western edge of the town will look towards Brighton as travelling etc. will be much easier, whilst patients to the East and North of Hastings will similarly look towards the hospital in Pembury.

We note that only some 750 lower risk patients will remain – an average of less than 3 per day, barely one operating session. These will have to be cared for, medically, out of hours by a surgical specialist, an expensive but necessary option. These specialists will also need to maintain their skills and interest, presumably by rotating to the other Hospital. Not attractive posts and ones that, in the longer term, may be difficult to fill.

These patients will also need to be cared for on a surgical ward – but there are insufficient to occupy a full ward so they will need to share with another specialty and, given that there will be a mixture of sexes, possibly in the same bay! This will defeat the Trust’s stated ambition of improving specialist care, since nursing staff will be looking after a mix of specialties.

We support the ambition to reduce the number of cancelled elective operations. However, from discussions with medical staff it is clear that the biggest factor in cancellation is not the emergency surgical patient, but the influx of medical patients at the time of peak activity. The Trust should, therefore, be looking to increasing the provision of medical beds.

Orthopaedic Surgery: We do not believe that the case put forward by the Trust is sufficient to justify the single-siting of these services. We note that there are already enough Orthopaedic Consultants to maintain the on-call rota. We also note that there is a discrepancy in provision of support services between the two Trusts. Since it has proved possible to provide this on one site, then it must be possible to provide it on the other. Elective patients can already be referred between sites if necessary. Out of hours, there will be little additional access to other specialists since they too will be taking part in the on-call rota. Emphasis is given to the ability to reduce cancellations but, as noted earlier, the biggest problem is the overflow of medical patients at the time of peak activity.

We are very concerned that the ideal model of care in the consultation document is the model already adopted in Eastbourne!

We are also very concerned that elderly patients with a fracture neck of femur will be transferred up to 20+ miles by ambulance to receive treatment that is currently available or could be made available to them in their home town.

Other Hospital Services: The Trust states that it is committed to maintaining A&E services at both hospitals and that both should be thriving general hospitals. However, how this ambition is to be fulfilled is not explained. The domino effect is a major concern for the population of both towns and we believe this to be a real possibility for the following reasons.

A&E: Currently both hospitals have A&E departments that have Trauma Unit status. However one unit will automatically lose that status on the implementation of the changes in these proposals. Paramedics attending incidents will take all patients with trauma or suspected trauma to either a Major Trauma Centre (e.g. Brighton) or the Trauma Unit in Hospital A where appropriate back-up will be available. These patients should not be brought to Hospital B. GP’s referring patients, or ambulances responding to 999 calls to patients, with suspected emergency or urgent surgical conditions will again refer to Hospital A. Hospital B will only see such patients if “self-referring”. The experience of treating such patients will be lost.

In addition many medical emergencies are, increasingly, being admitted directly to the specialty department concerned.

A&E staff will see fewer and fewer of the more complex cases that medical staff have spent many years training to deal with. Job satisfaction is likely to be low for Consultants who will not see their skills being put to best use and training will be very poor for training grade medical staff. Retention of good quality staff will be difficult as will future recruitment. The same reasons that have been put forward in attempting to justify the single siting of the other specialties!

How will this service be sustained? Linking posts on rotation with Town A may be a possibility for trainee staff – although not attractive, and unlikely to be satisfactory at Consultant level. One Consultant has indicated an intention to seek a post elsewhere should these changes favour the other Hospital – it is already difficult to recruit to such posts. As a result it is distinctly likely that A&E in Town B will gradually wither away.

Maternity, paediatrics and in-patient gynaecology are subject to a separate review which will report at an unknown date in the future. There has, already been one attempt to single site obstetric services. Should these proposals go ahead it will be much easier to deliver single-siting of obstetrics since the principle of the single site will already be established. Therefore, this cannot be ignored and must be taken into consideration when considering the future effects.

There are very good clinical reasons why general surgery and gynaecology should be on the same site. Women of child bearing years presenting with abdominal pain can either have a general surgical problem or a pregnancy related problem which, can rapidly become life threatening. Co-location of general surgery and gynaecology should ensure that any problems are rapidly dealt with by the appropriate specialty. It is almost certain, therefore, that urgent and complex in-patient gynaecology will eventually also be at Hospital A.

Currently both hospitals maintain a full on call anaesthetic service. This provides:

a)Out of hours anaesthesia for:

Urgent general surgery – which will be located at Hospital A.

Urgent trauma and orthopaedics – which will be located at Hospital A.

Urgent obstetric interventions (Caesarean Sections etc.) – likely to be located at Hospital A.

Epidural pain relief for childbirth – likely to be located at Hospital A.

Urgent gynaecology – likely to be located at Hospital A.

b)Support to A&E – primarily trauma and complex emergency surgical patients – all such cases will be referred to Hospital A.

c)Support to, and day to day management of, ITU – complex surgery and trauma patients will be located at Hospital A, and should not be treated at Hospital B without 24hr access to senior surgical expertise.

What will be left in Hospital B:

a)Out of hours anaesthesia for urgent complications arising in the low risk general surgical, orthopaedics and, possibly, gynaecology in-patients – should be very rare and, should they arise might also be transferred to Hospital A.

b)Out of hours anaesthesia for urgent surgery in the remaining surgical specialties eg, urology, ophthalmology, and ENT – infrequent.

c)Out of hours anaesthesia for surgical complications arising in inpatient medical patients – infrequent and likely to be complex, perhaps should be transferred to Hospital A.

d)Support and possibly day to day management of ITU for remaining types of patient.

e)Support to A&E for urgent cases involving resuscitation and/or ventilator support.

This will represent a dramatic change in the on-call workload of the anaesthetic department. Since much of the other work is likely to be relatively infrequent, the only major workload will be in ITU. The experience gained by trainee anaesthetists based at Hospital B will be strictly limited and such posts are unlikely to be recognised as suitable unless linked, on rotation with Hospital A – which will prove unattractive to future trainees. In addition trainee anaesthetists require Consultant supervision which must be local – it cannot be from a hospital 20+ miles away. Such Consultants will need to have an interest in and be experienced in ITU medicine – not all have that desire. How is this service to be maintained and will it be financially viable?

Low risk in-patient operating will still take place in Hospital B – patients will require medical supervision for the duration of their stay. “Out of hours”, this cannot be provided by unsupervised training grade doctors whose consultant is based 20+ miles away. Equally it should not be acceptable for doctors in other specialties to give such cover. This must, therefore, be provided by suitably qualified career grade staff – how will they maintain their skills in urgent and complex surgery? Some form of rotation will be necessary – will this enable sufficient numbers of suitable staff to be recruited. We are particularly concerned about the long term viability of employing medical staff of suitable quality in General Surgery where an average of less than three in-patient procedures per day are involved – this is a very expensive option, and likely to be reviewed very quickly.

All medical staff will be subject to annual appraisal and regular revalidation with the GMC. Whilst this should be very straightforward at Hospital A, it may not be so for any medical staff in the affected specialties based solely in Hospital B. Suitable arrangements to maintain the skills etc. necessary to satisfy these and future requirement will need to be made.

The above domino effect whilst a worst case scenario is a distinct possibility and should not be dismissed lightly and Hospital B, whilst still in existence could no longer be described as a “General” Hospital. The Trust must explain how it intends to prevent such consequences – to date it has not done so.

Ambulance Services: The Ambulance Service is not part of the hospital service but is an essential support to them particularly for the emergency admission and trauma patient. We note that the South East Coast Ambulance Service NHS Foundation Trust have been involved in the preliminary work on the proposals, support them and will continue to work with ESHT. We believe that the implementation of these services will have major consequences for the Ambulance Service and the emergency cover in the two towns.

Currently if a patient requires emergency/ urgent ambulance transfer into hospital from the environs of either town it is unavailable for another case for the duration of the journey to hospital and the time taken to offload the patient and any necessary cleaning that is needed. It is still within the town and rapidly becomes available for further cases.

On the implementation of these proposals, if a patient requires transfer from Town B to Hospital A, there is a much longer journey time and when finished at the hospital, the vehicle is still in Town A. This will reduce the emergency cover in Town B for a much longer period. This scenario is likely to be enacted up to 10+ times per day and is clearly unacceptable.

It seems to us that the solution will be either a) a big investment in new vehicles and additional ambulance crews or b) substantial movement of vehicles around the county to ensure an adequate level of cover is maintained in Town B or c) a mixture of both.

None of this is explained in the document and the public need to be reassured as to how an adequate level of cover is to be maintained.

Single Site: The Trust states that it does not have a preferred option, although there are suspicions that this is not the case. We firmly believe that the arguments against single-siting are overwhelming and apply equally to both hospitals and we also believe this will be the view of the general public. It is hoped that such opinion will be listened to, but experience from the previous public consultation does not auger well.

Should the final decision to single-site be agreed, then there is likely to be a division of opinion on partisan grounds. Deprivation is often cited as a reason for various decisions – however, as the document states, there is deprivation in both towns. In addition, whilst access to primary healthcare is a factor in deprivation, this does not follow for specialist hospital services. Deprivation is a problem for politicians at local and national level to address at its source – should, however, hospital services be deemed to be part of this, it is illogical to increase the deprivation in one town in order to reduce it in the other.

We have tried to address this question impartially, but believe that there are good clinical reasons that, should a single site be confirmed, this should be based in Eastbourne. Our reasons are:

a)A&E: Only one A&E will be a designated trauma unit. If this is based at the Conquest, then trauma patients form the Eastbourne Area will be taken by paramedics either to the Major Trauma Centre in Brighton or the Trauma Unit in Hastings. If a patient taken to the Trauma Unit is subsequently shown to require transfer to the Major Trauma Centre they will either be transferred back past Eastbourne to Brighton or further away to centres in London! If, however, the Trauma Unit is based in Eastbourne, then casualties from the Hastings area will either go to the Major Trauma Centre in Brighton or London, or to the Trauma Unit in Eastbourne. If subsequent transfer is required, the patient will be much closer to Brighton and valuable time will be saved.

b)Cancer Services: In the proposals for General Surgery, all major cancer surgery will be carried out at the single site. It is already planned that a Radiotherapy Centre will be built on the DGH site and due to open by the end of 2014. We believe it is sensible for cancer surgery to be carried out on the same site to facilitate good communication and discussion, between specialists and the patient, should radiotherapy be required post-operatively.

c)Orthopaedic Surgery: Orthopaedic surgery in areas of particular concern, such as fracture neck of femur, is already better developed in Eastbourne and it is sensible to build on that. To disadvantage patients from Eastbourne to make them travel 20+ miles to receive the level of care already provided cannot be described as an improvement!

d)It is believed that fewer patients would have to travel if the single site is Eastbourne and that the age of patients (increasing potential difficulty in travelling) is also greater for Eastbourne patients, although the differences may not be statistically significant.

Summary: The proposals put forward by East Sussex Healthcare Trust are very significant and have potentially far reaching effects on the specialties under consideration and other hospital specialties. Many of the benefits mentioned in the proposals such as improved care in the community can and should take place irrespective of other changes.

There may be small advantages to be gained by the single siting of stroke care, but with the planned additional CT facilities on both sites and the proposed introduction of telemedicine, these are counterbalanced by the travel difficulties for both patients and visitors which have been overlooked.

We cannot support the proposal to single site emergency and high risk General Surgery and Orthopaedics. The only real benefit is the reduction in on-call in General Surgery. The consequences for the hospital without such provision have either been overlooked or played down. The Trust denies the potential domino effects, but fails to explain how they will be avoided. These consequences outweigh any advantage of single siting.

Should other opinion agree with us, the proposals should be rejected, and as such the choice of site is irrelevant. However, should they go ahead we believe that there are good clinical reasons for opting for the District General Hospital, at least for General Surgery and Orthopaedic Surgery.