Concern for Health in East Kent

2.1 Whilst this document is primarily intended as CHEK's formal response to the East Kent Hospitals Trust (EKHT) and East Kent Health Authority's (EKHA) consultation document 'Modernising Hospital Services in East Kent' (MHSiEK), it is aimed at a far wider readership including the Department of Health, the government's PFI Task Force, Members of Parliament, County, City and Town Councillors, and prospective PFI partners.

Background

3.1 Following an extensive consultation exercise during 1998, the then Secretary of State, Frank Dobson gave his very qualified endorsement to plans proposed by EKHA to reduce the three acute hospitals in East Kent - Ashford, Canterbury and Margate, to two - Ashford and Margate. Mr. Dobson made several highly significant amendments to the plan which have proved to be the root of three years of muddle, confusion and prevarication.

3.2 Although the results of the consultation, entitled 'Tomorrow's Healthcare' appeared to be a ringing endorsement of the plan, this was only achieved through extensive and judicious 'weighting' of the results.

3.3 Examples of weighting include:
* 99 out of 101 GPs responded negatively but this was weighted down to 8.
* Every single pre-stamped postcard (promoted by the Thanet Trust) was counted as a unit of approval, each of the town councils and town councils expressions of disapproval were also counted as a single unit of disapproval.

3.4 It is adequately illustrated by comparison of the Canterbury and Thanet CHC's total written responses and EKHA's total written responses. CHC written responses EKHA written responses

C&T CHC Written responses EKHA Written responses

3.5 This is ancient history now but still relevant, as it serves to set the scene of a reconfiguration which was pushed through against the wishes of the population in spite of declarations to the contrary.
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The Dobson Decision

4.1 The principal changes that the S of S made to EKHA's plan were

* That there should be 232 beds instead of the 65 proposed at K&CH
* The Cancer Centre must be retained
* The Coronary Care Unit must be retained
* Acute medical admissions must be retained
* Arrangements for Accident and Emergency were unsatisfactory and must be revisited
* Arrangements for Renal services , Vascular services and haemophilia services must be subject to further review and consultation.

4.2 EKHT has spent three years attempting to make this formula work. Many hundreds of hours have been spent by the Medical Module Committee of the Clinical Staff Committee in trying to solve the conundrum (we have the minutes of most meetings); the Durrow Consultancy was commissioned by the Trust to solve the problem (we have their reports). They failed.

4.3 York Health Economics Consortium was commissioned to produce a module. They produced two documents outlining number and distribution of beds. The first was published but the second has never seen the light of day (we have both).

4.4 Various documents outlining implementation plans have been published by the Trust board. Exhibitions and roadshows have been mounted to inform the public, and the PFI group was set up - led by Matthew Coats and drafting in Mrs Liz Cracknell. The SOC was produced and approved by CPAG in February 2001.

4.5 All of this in the sure and certain knowledge that the Dobson plan could not and would not ever work. The effect on staff and services of this deception and the three years of prevarication has been manifest by the appalling deterioration in service delivery, particularly over the last 18 months.

4.6 It was not until EKHT had to commit themselves to the Outline Business Case (OBC) that they had to own up to this failure. We do not blame them for this, only the extraordinary length of time it took - causing three years of uncertainty, bluff and instability. Clinicians knew it wouldn't work from day one.
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The Strategic Outline Case (SOC)

5.1 This document entitled 'Moving Forward' was, in our opinion, a lazy, shoddy document, full of false assumptions, inaccurate statistics and spurious arguments. However, as it was made public only after its approval by the NHS Executive SE Regional Office and the PFI task force, we were unable to publish a contemporaneous response.

5.2 There is little point in discussing points from 'Moving Forward' which arise again in MHSiEK. However the following is worthy of mention:

5.3 The document frequently claims that training accreditation would be withdrawn by the Royal Colleges. Anaesthetists, Physicians and Surgery are mentioned specifically. We understand that there is little or no truth in this statement. The RCA has recently renewed accreditation with highly complimentary comments, particularly about Canterbury. The RCS has also recently renewed accreditation and the President, Sir Peter Morris has written to us stating, "I am not aware of the basis for this statement which also appears in the above document..." Similar comments have been made by Prof Alberti of RCP.

5.4 We note the fact that the subject is not even raised in MHSiEK.
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'Modernising Hospital Services in East Kent'

6.1 For ease of reading, this document will more or less follow the structure of the MHSiEK, and comment on it page by page. This does not reflect our consideration of priorities. This is outlined in the Response Summary.

Introduction

6.2 The document makes no secret of the fact that the entire appraisal and consultation process has used the Secretary of State's decision of December 1998 as the benchmark by which options have been created, assessed and short listed.

6.3 The government's Capital Investment Manual (CIM) makes it unambiguously clear that the process should be started from scratch and that:

“The aim is not to provide justification for a course of action that has already been decided“ (1.1.4)

6.4 The Trust was further released from the SoS's decision by the Health Minister Hazel Blears in the adjournment debate on 30th October 2001:

“The chosen option... was right at the time that it was taken. However, we are three years on and we have seen the introduction of a whole agenda for clinical governance. We must therefore reconsider whether that configuration would still be able to meet present-day needs.“ (238WH)

6.5 The last para of the Introduction states '...all options recognise the value of East Kent's hospitals and play to their strengths'. This utterly fails to acknowledge that K&CH's exceptional skills, clinical and human resources and specialisms are at worst on a par with WHH and QEQMH but many would claim were superior.

6.6 It is the fact that many if not most of K&CH's exceptional strengths are being gradually dissipated by the threat of downgrading that is possibly the most depressing aspect of this whole procedure.

6.7 The CIM states throughout that the Trust must, from the outset, articulate the objectives underpinning the proposal, and that respondents should be able to compare the options with the objectives they are intended to achieve: 'Pre-requisites for an NHS Trust considering a capital investment are that it has a clear, documented business and service strategy...' (First Phase: Strategic Context (Step 1) The document also defines the territory into which those objectives should fall: 'A guiding principal is that objectives, and the benefits that flow from attaining them, must be determined by consumers (i.e. patients) needs, and reflected in purchasers' demands for the range and level of services to be provided'.

6.8 We can find no clear statement of objectives anywhere in the document.
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Why we have to change

7.1 There can be no denying that the health service and East Kent in particular, does face significant challenges. CHEK enthusiastically supports the concept of modernisation and is not fearful of change. But it must be considered, evidence based change that benefits patients. This must be the over-riding criterion.

7.2 MHSiEK (on page 18) outlines the four principal drivers for change and we fully acknowledge that each does indeed present a challenge to the Trust. What is not assessed is the scale of the problem and whether the scale of the solutions (options) are proportionate to the problems.

7.3 It is our belief that the scale of the problems in no way justify the radical, destabilising, prohibitively expensive root and branch reforms proposed and that they are 'a sledgehammer to crack a walnut'.
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The 'New deal (ND)' and the 'Working time directive (WTD)'

8.1 10 years ago it was not uncommon for junior doctors to be working up to 120 hrs per week. The ND reduced this to 72 hours. The WTD has now reduced this to 60 hrs and will reduce it to 48hrs by 2009. Compliance is mandatory and Trusts are fined if they are not compliant. When ND was brought in, there were prophets of doom predicting that the whole system would implode. This has not happened, and the reduction of working hours by half has been largely painless.

8.2 Similar predictions are now being made about the WTD. Nobody is suggesting it will be easy, but virtually every major industry has had to cope with the imposition of a shorter working week and they have done so by the sound, innovative management of logistics, job roles and productivity rather than by reducing output or closing services. The banking industry is a prime example. With a similar scale of logistics, non-viable outlets and top heavy management, the industry has massively reduced its staff by and revolutionised its structure, working patterns and practices. Though painful for the many thousands of staff who have lost their jobs, consumer suffering has been minimal.

8.3 Junior doctors have always been the clinical backbone of the NHS. They have been mercilessly exploited, made to do work which is beneath their skill level and picked up the pieces when the going gets tough. Things are changing but there is a long way to go. With the advent of specialist nurses and nurse practitioners, and changes to the roles of both senior nurses and consultants, junior doctors are more able to concentrate more what they are there to do - diagnose and treat patients and increase their knowledge and skill base.

8.4 The BMA is about to publish a book with guidance and recommendations for the changing roles of consultant physicians. The principal of their approach is that services should be much more consultant based rather than consultant led. It is felt that the old method of 'watching and helping' is more valuable than the current trend for remotely supervised independence. Thus more juniors can be instructed at the same time; the range of patients is greater and most importantly it maximises use of juniors' time.

8.5 The new consultant contracts have been devised with this methodology in mind and BMA's consultations with its members have had a very positive outcome.

8.6 Other NHS Trusts are looking at these kind of innovative alternatives and changes in working practices but EKHT/EKHA seem to believe that the reduction of services is the only solution.

8.7 Of course one solution to the shorter hours problem is simply to employ more junior doctors. However hospitals are still suffering from the severe cut backs in training places during the early 1990Õs and thus juniors at the right stage of their training are at a premium. There is plainly also a financial implication to this approach.

8.8 Over the last 18 months, the government has put huge numbers of new recruits into training. These students will be qualifying and looking for placements at just around the time the re-configuration is due to happen. Thus if increasing the number of junior doctors is at least part of the solution to the ND and WTD challenge, it will be a much lesser problem in 5-7 years time.

8.9 Junior doctors want to increase their 'productivity'. After all, in order to qualify for promotion they must see a set number of patients and range of cases, and do not want the reduction in their hours to mean they have to work many more years before qualifying.

8.10 It is thus our opinion that with skilled, innovative management of resources, changes in working practices and team work, this challenge can be met without radical reform of the type proposed.
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Sub-specialisation

9.1 The sub-specialisation argument would have been convincing if arguing for a single site option. For any multi-site option (2/3 or more) it makes little sense and could even make matters worse.

9.2 To consolidate a sub-specialisation on one site (which in many cases would seem more appropriate) - perhaps with spokes or out-reach clinics at the other sites, means that all patients with that complaint would have to be transferred to that site. It would make little or no difference whether those patients were transferred from one site or two. At best it would improve matters by one sixth (the difference between one half of patients and two thirds of patients).

9.3 If specialities are to be centralised on one site, it is imperative that that site is at the centre where it allows best access to the most patients; would cause the least travelling for junior doctors and other trainees on rotation; and cause the least time wasting for busy consultants who may have to assess patients on other sites. In other words at Canterbury.

9.4 Sub-specialities are required by a small minority of patients - and in most cases the condition would not be termed an emergency or immediately life-threatening (e.g. urology, ENT). In other words, in the majority of cases, a transfer to a different site would not pose a problem. Of course there are exceptions such as acute renal failure.

9.5 If there are sufficient patients to justify siting the speciality on two sites then WHH and QEQMH are the obvious choices.

9.6 In short, there is no question that there would be considerable benefits in the centralisation and consolidation of sub-specialities. This could be a comparatively painless solution to what is, in any case, not the major problem which MHSiEK suggests it is.

9.7 Conclusion: this is clearly not a problem of a magnitude that demands the radical, destabilising root and branch reform proposed.
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Recruitment.

10.1There is little doubt that recruitment to some senior posts has proved a major challenge in East Kent over recent years. However it must be noted that until the 'Tomorrow's Healthcare' proposals, K&CH (in particular) had little difficulty in attracting highly qualified staff and that it has been the uncertainty about the future that has made recruitment and retention difficult.

10.2 Over the last two years K&CH has lost a number of irreplaceable staff, most of whom would have stayed had it not been for the demotivating effect that threats to their departments, their teams and their ability to perform their duties, had had.

10.3 There is a national shortage of certain key skills. The MHSiEK document highlights pathology but there are many others including obstetrics, haematology, anaesthetics, renal and radiology. It is our opinion that the problems relating to recruitment are compounded by two factors. First that the instability and ambiguity about the future of services in East Kent is proving a disincentive to people who would otherwise have been attracted to the area; and that EKHT is not particularly adept at recruitment.

10.4 This can be demonstrated by two examples. A highly qualified radiologist who until recently worked at the Royal Free wanted a more challenging position, possibly out of London. She looked seriously at K&CH but when she spoke to the Royal Free's HR department they said 'you don't want to go there - they're closing down'. (The Chairman of the Royal Free is Sir William Wells - ex Chairman of the NHS Executive SE). i.e. disinformation about the K&CH (in particular) is common and has gone unchecked by EKHT HR dept.

10.5 The radiologist applied for several NHS posts and one private post. The private hospital responded almost immediately and organised an interview and assessment within a couple of days. They offered her the job on the spot. She left the NHS and started last December. The interviews and assessments for NHS jobs would not have even happened yet.

10.6 When the Royal College of Anaesthetics visited East Kent to consider its re-accreditation, they commented on how hopeless EKHT was at recruiting. 'Other trusts sponsor promising candidates in their last year at teaching hospitals, or recruit the crème de la crème before they've even left, EKHT put an ad in the paper and wait for the phone to ring'.

10.7 In short, we believe that with the attraction of East Kent as a relatively prosperous, safe and pleasant area to live and work, and with Canterbury in particular having a wealth of modestly priced 'student' accommodation, recruitment would not be the problem it is currently proving if the Trust reclaimed its reputation as a career enhancing place to work. And if the future shape of services were less unstable, and if the EKHT HR department were somewhat more creative in their recruitment techniques, we believe this would not be a significant problem.

10.8 With the huge increase of doctors and nurses in training, this would in any case, be a progressively smaller problem.

10.9 Particular concerns about recruitment to QEQMH are dealt with in 25.8.

10.10 Conclusion: This is a very real problem, but a problem which is very much of the Trust's own making, and within its own initiative to solve. As thus it does not come close to justifying the course of action proposed.
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Consultant teams.

11.1 This is such a small and minor problem it is hardly worthy of discussion. It has never been raised as a problem, let alone a 'driver for change' in any preceding documents. It is another example where the lack of skilled management has created a problem out a situation which need not even exist.

11.2 Conclusion: This is not even a real problem, let alone one which justifies the course of action proposed.

12.1 It is clear from the above that the case for wholesale, dramatic, radical, root and branch reform has not been made. There is a very good case for a limited amount of centralisation, consolidation and reorganisation. This would be a true and creative modernisation and the risks, destabilisation and costs would be minor compared with the proposed.
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The Options

13.1 We do not propose to analyse each of the option individually and make comments. This is because we believe that each of the options is flawed but principally because none is affordable and would inevitably lead to bed, service and staff cuts. We will however make a few general comments:

13.2 Option A is presented as the 'Dobson Option'. It is not the Dobson Option. Mr. Dobson stated that there must be 232 beds and that the Cancer Centre must stay at K&CH. However the principal of retaining Medical admissions is part of Option A.

13.3 EKHT has spent hundreds and hundreds of hours over the last three years trying to find a way to make the Dobson decision work. When their Medical Model committee had failed they hired the Durrow consultancy to solve it. They also failed. It is simply not possible.

13.4 We therefore fail to understand why it is even offered as an option (even in its scaled down form). It is even less viable than the 'no or little change' option which was dropped.
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The Appraisal Process

13.5 As mentioned above, the CIM makes it clear that any and all viable options must be part of the appraisal process and that this should be started from scratch, rather than using an existing decision as a bench-mark.

“The generation of options provides an opportunity to be creative and innovative, to challenge constraints, and to re-visit the objectives of the investment.“ (2.12.1) The evidence suggests that this was not the approach undertaken by the Trust.

13.6 The PFI team did meet with a number of clinicians to canvass ideas and responses. We understand that a wide variety of ideas were forthcoming. And yet they have all been rejected and the entire process appears patronising rather than inclusive.

13.7 When the shortlist of five options was established, the Trust failed to show them to the Clinical Staff Committee whose approval and participation is considered an essential to the proposal going forward. The CIM states that it is,

'...vital that all NHS Trust staff who may be affected by the proposed capital investment are consulted and given appropriate opportunities to participate in the decision making process' (Introduction) (our emphasis)

13.8 In order to arrive at a 'preferred option' the Trust undertook a series of meetings with clinicians. 600 individuals were invited but only 176 participated. Some staff accuse the Trust of 'cherry-picking' the participants and choosing times and locations for meetings which ensured a poor attendance.

13.9 On the basis of that 'consultation', the outcome was announced at the Trust board meeting of 7th Sept 2001. Observers at that meeting were left in no doubt that the 'preferred option' was to be Option 5. Media, staff and public hostility caused the Trust to back-track and say there was no 'preferred option' and that a public consultation would be undertaken.

13.10 The Trust made (what appears to have been) the unilateral decision to exclude Option 1 (the 'no or minimum change' option) from the consultation.

13.11 Although CHEK agrees that the status quo (no change) would be an unwise course of action, the preclusion of this option has denied respondents any opportunity to reject the bi-polar formula. This was presumably the intention.

13.12 Conclusion: We believe that the option appraisal process was not objective; that viable alternatives to the two site formula were ignored; and that there was insufficient consultation with staff and stakeholders.
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Deliverability

14.1 The notes accompanying each of the options (except Option D) cast major doubt on their deliverability.

14.2 We have to question why any options were presented in which the Trust did not have 100% faith and confidence. It raises the question of whether there will be another three years of prevarication whilst extremely busy senior professionals again try to make the unworkable work.
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The House of Cards

15.1 We have dealt with these issues in 'why we have to change'.

15.2 We feel this page would be better described as the 'house of straw', because one gust of logic, common sense, and sound judgement make the arguments collapse.
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