Concern for Health in East Kent

16.1 In 1996 The National Audit Commission undertook a detailed survey - 'Accident or Luck' - of every A&E department in the country. This was updated in 1998. (this document was widely quoted in 'Better Balance' to justify the HA's course of action). The NAO was even more extreme than the government in their recommendations that there should be fewer, larger A&E departments. They believed that as many as two thirds of the country's A&E departments did not justify their existence and should be merged.

16.2 They produced two principal criteria for the existence of an A&E department. It should:
* Be at least ten miles from the next closest
* It should serve at least 50,000 people.

16.3 Currently the three A&E departments (18 miles apart) see about 152,000 people per year, split more or less equally between WHH, K&CH and QEQMH.

16.4 For many years EKHT/EKHA has claimed that 70% of A&E presentations could be treated by a Minor Injuries Unit (MIU). This claim has been consistently disputed by both staff and professional observers.

16.5 In the course of their monthly Casualty Watch, the Canterbury & Thanet Community Health Council has estimated the figure to be, on many occasions, as low as 30%. Dr Sue Brooks, who was Consultant in charge of A&E at K&CH until she resigned in 2000 estimated the figure to be 40%.

16.6 MHSiEK now admits the figure to be 58%. On the basis of all evidence, it would thus seem safe to assume that approx half of A&E patients could be safely treated by an MIU - i.e. around 26,000 per year from each site.

16.7 The implications on the transport infrastructure of this number of extra journeys between Canterbury and Thanet/Ashford are profound. Almost a million extra journey miles would be required (26,000 x 18 miles both ways = 936,000 miles). Add to this visits by relatives and follow up appointments and the two thirds of (non low-risk) births which would have to transfer; plus half of all elective activity. 16.8 We estimate that the total would would be close to 2,000,000 extra journey miles per year - most along the winding, bumpy, single carriageway A28.

16.9 The Kings Fund in conjunction with the Royal College of Physicians has estimated that about 0.5% of patients arriving at A&E are in a critical or life threatening condition. This would account for around 250 patients per year from Canterbury alone. It is inevitable that for a proportion of these patients the extra 18 miles and 30-40 minute journey would mean the difference between life and death, and for others the quality of their outcome would be compromised. If even around one in ten of these patients died EKHT/EKHA would, each year, be responsible for almost the same number of premature deaths as the Omagh bombers.

16.10 EKHT/EKHA may view this number of premature and unnecessary deaths as collateral damage and a price worth paying for the reconfiguration. We do not. We consider one unnecessary death to be too great a price to pay.

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16.11 It is also totally contrary to the principal aims of the NHS Plan and HImPs, which target a 20% reduction in premature deaths.

16.12 We note that when discussing both A&E and Coronaries, MHSiEK states that the extra time and distance would make little difference in almost all cases. This is an overt admission that it would make a difference in some cases.

16.13 The Kings Fund have calculated that 65%-70% of patients occupying a hospital bed have arrived there through the 'gateway' of emergency services (blue light, A&E, GP admission). It is thus doubtful that even the much reduced numbers of beds at K&CH in Options A-C could be filled without wholesale transfer of patients from the other hospitals.

16.14 Dr Richard Taylor - MP for Wyre Forest, whose Kidderminster Hospital has already gone through a very similar re-configuration, has told us of some unforeseen consequences of closing Kidderminster's A&E dept.

16.15 Many patients are admitted to A&E for treatment and discharged on the same day. This is called Zero Length of Stay (0LOS). For Kidderminster patients going to Worcester A&E, 0LOS has all but disappeared. The logistics of transporting patients back and forth on the same day has proved too much for the system to cope with. (Worcester is only 10 miles from Kiddermister, WHH and QEQMH are 18 miles from K&CH.) This has had severe implications on bed usage and trolley stays in A&E.

16.16 The other unforeseen consequence is that consciously or unconsciously, Worcester clinicians are giving priority to Worcester patients and treating Kidderminster patients as 'second class citizens'. This is already happening here too. We know of at least one case where a Whitstable patient was discharged prematurely from WHH 'because an Ashford patient needed the bed'.

Cancer

17.1 Although Options A and, to a greater extent Option C, present what appears to be a reasonable baseline portfolio of Cancer services, this would be a universe away from the range of services which are currently available at K&CH.

17.2 Embedded within all 4 options is the principal that the worse your condition and the more unpleasant your treatment, the further you will have to travel.

17.3 It is our belief, and that of most involved observers, that this is utterly contrary to the spirit, if not the letter of Frank Dobson's decision, that a similar, if not increased level of cancer services should be maintained at K&CH.

17.4 Staff who work in the cancer field have stressed to us that the entire service is based on teams. Of course the equipment - scanners, LinAccs etc are vital but it is the collaborative approach to treating tumours which is successful. A patient's course of treatment will rarely be decided by one consultant. A team, perhaps including a haemotologist, oncologist, surgeon, radiologist and anaesthetist will sit round a table a devise a treatment plan. It is this team approach to treatment which has been so successful in the past and resulted in the K&CH Cancer Centre being the first Charter Marked unit in the country.

17.5 It is our belief that the claim that 80% of patients will continue to be treated at Canterbury hides a multitude of sins. Instead of patients being treated by teams, under these proposals it is quite possible that a patient may be diagnosed on one site, operated on at another, have chemotherapy at another and radiotherapy at yet another. Apart from the stress and inconvenience caused to the patient, the patients outcome is unlikely to be as successful because the various consultants have not conferred. Certainly not to the degree possible when all in the same room together.

17.6 It should not be forgotten that most Cancer treatments are extremely unpleasant and debilitating, and that most patients feel extremely unwell.

17.7 The government's Cancer Plan makes as an absolute priority that patients should be treated as close to home as possible. All of the options will make treatment further away from home an inevitability. This will effect Thanet patients more than any others.

17.8 Over recent months, Cancer services have been allowed to 'wither on the vine'. Two senior haematologists have been 'allowed' to leave - one taking early retirement and the other for a job in Eire. They have told us that it was the 'centralisation' of Pathology in Ashford, the lack of clarity in their management structure, and lack of support from Trust management which were actually responsible. The service is now being essentially run by locums, and the one haematologist who was recruited to QEQMH is currently under suspension.

17.9 The Head of Cancer services (Dr Stuart Coultart) has stated openly that in the next few weeks there will have to be a drastic reduction in the range of tumours that can be treated at Canterbury because of the retirement of a senior specialist.

17.10 For any Cancer Services (or their adjacent services such as acute Renal and HDU) to be removed from K&CH would be an utter betrayal of all East Kent's cancer patients. Statistics show that one in three of us will get cancer at some time in our lives. Thus, over time, more than 200,000 East Kent residents will have to travel either to Maidstone or to London for treatment that would have been available locally.
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Affordability

18.1 It is our fear and suspicion that the reason why the downgrading of K&CH has remained an imperative, is that land would be gifted to the PFI partner(s) in order to reduce the annual unitary payment, as is outlined in the document 'Land and Buildings in PFI schemes'.

18.2 If this is the case, this would be a gross miss-use of the PFI process, which it supposes that all investment strategies are driven by improvements to quality and service delivery. Of course land which is surplus to requirements should be used to reduce the financial burden, but to engineer the vacating of land purely in order to make the project more affordable would be entire wrong.

18.3 The CIM states frequently that the first priority must be that a project is affordable and that it represents value for money. For example:

“A business case must convincingly demonstrate that the project is economically sound (through an option appraisal), is financially viable (affordable to the Trust and its purchasers) and will be well managed.“ (CIM Introduction)

18.4 It is understood that estimates of the costs involved in implementing the re-configuration have risen to £150m, having started at £52.5m. This represents an frightening increase of 46.8%. Howard Jones (Facilities Director) has stated that this is the cost of increasing acute bed capacity by 175 beds.

18.5 The SOC estimated costs at £102.2m and that the repayment exposure would be £29.8m per annum. Of this £19.8m would be transferred facilities management costs plus the transfer of risk, leaving at total of £10m per annum of 'new' money required.

18.6 It is assumed that the extra £47.8m would be principally capital cost and that facilities management costs would only increase slightly (we have assumed 5%).

18.7 We can thus extrapolate that with a total cost of £150m the annual unitary payments would be in the region of:

Capital cost Hard FM Soft FM Cost of risk Estimated UP	Current - 7.8 12.0 - 19.8	SOC 7.4 8.5 12.0 1.9 29.8	OBC* 10.85 8.93 12.6 2.8 35.18
*We acknowledge that in the absence of the formulas by which the SOC figures were calculated, these are assumptions. They have been calculated as follows: Capital cost = 217% of total cost/30; FMÕs = SOC + 5%; risk = 1.86% of total cost.

18.8 This would require £15.38m of 'new' money per annum.

18.9 The SOC states that the maximum affordability for the Trust is £251m per annum. In year 2000/2001 the Trust cost £246.527m to run. (Income of £247,128m minus surplus of £0.601m).

18.10 To add £15.38m to these running costs would total £261.907m per annum - way beyond the £251m pa affordability ceiling stated in the SOC.

18.11 In fact the 2000/2001 surplus of £601,000 was phantom. The Trust had been running at a £2.2m deficit until January 2001 when magically £2.8m was found to take the accounts into surplus. This has never been credibly explained.

18.12 For most of 2001/2002, the Trust has been forecasting an operating deficit of £8m. Again it seems that money has been unexpectedly found from somewhere, and they are now forecasting a £4m deficit. It would be rash to base any future projections on the opportune appearance of income at the last minute.

18.13 Ruth Carnall, CE of NHS Executive SE has recently demanded categorically that all Trusts in her region achieve break-even by March 31st 2002. Without major cuts, we do not believe that this is possible or likely.

18.14 In the absence of any proposals for substantial cuts in costs or sources of new income, (apart from land sales), all the options are plainly and conspicuously unaffordable, do not represent value for money or demonstrate any concept of financial governance.
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Access/Transport

19.1 East Kent's transport infrastructure can be categorised as NW to SE - good; NE to SW - poor. Rail and road connections between the ports and London are excellent and currently subject to major improvements. Connections across the county i.e. from Margate to Ashford are extremely poor. The A28 is for the majority of it's length single lane, windy, bumpy and subject to speed restrictions.

19.2 The Thanet Way which follows the estuary is a new road but frequently afflicted by flooding. In any case it 'runs out' long before Margate , requiring a tortuous route through Birchington and Westgate and through the back streets of Margate to access QEQMH. For this reason, ambulances tend to favour the A28, for all its faults.

19.3 The HA/Trust undertook travel time studies as part of the THC process with the Kingswood Consultancy. These findings have been consistently challenged, particularly in a study by Christchurch University College, but which was discounted because they did not include Swale in their investigations. Individual experience of journey times between the three centres suggest the Trust's figures are highly dubious.

19.4 A recent Trust survey has shown that all ambulance traffic (blue light or not) would reach its destination within 40 minutes. We challenge anyone to drive legally from K&CH to either QEQMH or WHH in 40 minutes at virtually anytime of day. We believe that these estimates are vast exaggerations.

19.5 Rail links are slow and infrequent and do not operate in unsociable hours. There is no direct rail link between Faversham and Ashford, and the journey via Canterbury requires a transfer between Canterbury East and Canterbury West - a distance of 2 miles. The last bus between Ashford and Canterbury leaves at 17.48. The Stagecoach bus link between Whitstable and Margate has recently been scrapped.

19.6 The map (above) shows all the acute hospitals in South East England but excluding K&CH. It is noticeable that all major and minor towns are within a 15 mile catchment of an A&E apart from this area, where 4 major towns (Dover, Folkestone, Faversham and Canterbury) and several minor towns, are well outside a 15 miles radius.

19.7 However reluctantly, patients may have to accept that they have to travel further for non-urgent and elective treatment. It is access to acute and emergency treatment that is the real concern.

19.8 For a heart attack or major trauma victim to have a 40 minute journey along the A28 in the back of an ambulance, will without doubt reduce their chances of survival or the speed and quality of their recovery, however successful their stabilisation by paramedics.

19.9 Door to needle times are considerably under target even with three A&Es. Without a Coronary Care unit at K&CH that time at least 40 minutes would be added. Without resident anaesthetists (as is planned), coronary patients could not be treated at K&CH.

19.10 An A&E physician points out that very few patients with chest pains can be immediately and unambiguously be diagnosed as having had a cardiac infarction - it could for example be an aneurysm. Thus even if paramedics are, in the future, permitted to administer single shot thrombolitics, (Tenectaplase), it would require them also to take on a diagnostic role for which they are not qualified.

19.11 We note that in the cost breakdowns in 'Moving Forward' there is not one penny allocated to the improvement of transport infrastructure. This is entirely down to the initiatives and financial capabilities of the KCC. The KCC is currently running at a deficit and is currently identifying major cuts in services and provisions. Transport is one of them.
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Outpatients

20.1 After extensive discussions with senior clinicians, we express extreme doubt about the sustainability of some outpatients clinics and consultancies.

20.2 When a consultant is taking an outpatient client on the same site as his in-patients he is effectively (if not technically) on call. It is not uncommon for a consultant to be called the ward between outpatient appointments and this generally causes little or no delays.

20.3 However if the consultant's in-patients are on a different site, this would be impossible. This would mean that either outpatient consultations are undertaken by lower grade doctors or in-patients may not receive the care and attention necessary.

20.4 Predictions are that under these options, outpatient clinics would be rapidly become outreach clinics - handing a vastly reduced number of patients, most of whom would not be first referrals. Thus first, or urgent referrals would have to travel to one of the main sites.

'Bed Blocking'

21.1 Delayed Discharge or bed blocking is an ever increasing problem.

21.2 Consultants calculate that the majority of 'bed blockers' are occupying beds unnecessarily because of faults in the system, as well as because they have nowhere to go.

21.3 Many patients are made to wait for entire weekends or during the week, entire days, because there is no consultant to discharge them. There is also a particular problem with delays in the provision of medication by pharmacies.

21.4 East Kent has lost around one third of its beds in homes for the elderly and we are continuing to lose about 3 homes per month. And to quote Ian Sturgess, Head of HCOOP "some of them are the good ones". We believe that there are four principal causes.

21.5 First is the government's 'Care Standards 2000' legislation (previously called 'Fit for the Future'), which imposes standards on homes which are beyond the means - financially and physically - of many. We have had many reports that EKHA are imposing these new standards in a bureaucratic and pedantic manner. It is unclear how much discretion they actually have, but it appears that whatever they have, they are not using it.

21.6 Secondly, there is a dire recruitment problem. This is principally because unskilled or semi-skilled carers are paid so little , because homes are able to command such low fees, particularly from the public sector. It has been suggested that the Trust re-employ carers from homes that have closed, but their HR director stated that they just seem to disappear into the ether. They surely must have access to employment records?

21.7 Third, and this is a particular problem in this part of England, that some homes have decided to house asylum seekers because they are paid around £70-80 per week more than for an elderly person.

21.8 And fourth, that property prices have risen to such an extent that home owners are literally cashing in to avoid the risk of insolvency.

21.9 It must be noted that there is a school of thought that many patients are being discharged too soon. The readmission rate within 28 days is rising dramatically - up 14%. in just one month (Aug-Sept 2001).The Trust no longer publishes actual figures.
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Implications for each hospital

Queen Elizabeth the Queen Mother, Margate.

21.1 All of the options would require a substantial expansion of QEQMH -by between 200 and 400 beds or between 8/10 and 16/20 new wards. Option D would make QEQMH one of the biggest DGHs in the country. It is difficult to envisage the logistics of how this would be achieved. There is no vacant land around the site, so the only possibility is to build higher. This is disproportionately expensive. A not dissimilar Toronto hospital (Western General) of a similar size decided to add an extra floor to create more capacity. To take the roof off, build the extra floor and replace the roof cost $350m - more than the hospital had cost to build in the first place.

21.2 Because of the design of the QEQMH building, there is every reason to believe that any upward expansion at Margate would be similarly expensive. We also understand that Thanet Council have planning restrictions on height which may preclude the addition of more than one floor.

21.3 What can not be built 'up' is parking spaces. The car park is already full most of the time and would be totally unable to cope with the kind of extra numbers that each of the options envisages. This would require an underground car park - again, disproportionately expensive to build.

21.4 It has always been suggested, if not articulated, that when (if) K&CH was downgraded, QEQMH would inherit much of its portfolio of specialities and services. This would not be the case. Almost all of the sub-specialities - such as ENT, Urology, cold Pathology etc. are to be sited at Ashford. The only exception, according to MHSiEK, is Renal and Vascular in-patients.

21.5 However it is our informed belief that these services will not go to QEQMH and will indeed possibly leave East Kent altogether. This is because a Cardio-Thoracic unit is to built at Pembury. It would be highly illogical and impractical if Vascular was not adjacent to or part of this unit. It was established by the committee examining the future of Renal services that Renal should always be adjacent to or part of Vascular services.

21.6 Neo-natal Intensive Care is another concern for Thanet patients. The unit, currently at K&CH (i.e. within reasonable access for Thanet) is according to MHSIEK, moving to Ashford. Our information is that it will in fact move to Medway. The Kent Ambulance Trust has recently stated that it is reducing the number of vehicles capable of carrying incubators.

21.7 As an indication of the situation to come, Thanet residents are already suffering from the 'centralisation' of Head & Neck at Ashford. QEQMH is refusing to treat patients with, for example nose bleeds or throat obstructions and sending them to WHH. And they are refusing to provide transport unless the condition is considered life-threatening. The majority of ENT patients are either young or old. These are the groups for whom an 80 mile round trip is proving the most harrowing. Ashford commented to one a CHEK member last week, that it was 'absurd that their clinic was full of people from Thanet with nosebleeds'.

21.8 QEQMH, more that the other two hospitals, has experienced severe recruitment problems. There are various reasons for this.

21.9 Consultants, as a 'breed' tend to move jobs very infrequently. They are unlikely to view a move as either short term or as part of a career path. The reputation and credentials of the hospital are thus critical to attracting senior staff. QEQMH has rightly or wrongly failed to make a mark as a centre of excellence - perhaps because it is so new, perhaps because Margate is not considered a desirable place to settle. So whilst consultant posts are being filled, they are often not with people with the experience and of a calibre that would be preferable. Some are attracted by the use of 'golden hallos', generous moving allowances, etc.

21.10 This is further evidenced by the latest figures published by the Trust, which show that consultant vacancies are as follows:
Ashford 6 Canterbury 4 Thanet 12

21.11 Middle and junior ranking doctors are less of a problem because they are often on rotations or short term contracts. With so many extra students currently at medical colleges, it will become easier to recruit when they start looking for placements in 5 years time.

21.12 Nurses are the biggest problem. Nursing staff are generally recruited from the generic population. This is because they have families, settled homes, children in school, husbands in local jobs etc. Thanet's population is unlikely to rise or to change its socio-economic profile dramatically.

21.13 QEQMH is struggling to fill nursing posts now, so the problem would only get worse if the hospital got bigger.

21.14 There was always an assumption, that when (if) K&CH was downgraded, staff would simply relocate to Margate. Because of EKHA's tactics during the 1998 consultation, which were to set hospital against hospital, town against town, there is an antipathy between the two sites. Many K&CH consultants have said they will not relocate to QEQMH and with a national shortage of senior staff, there are many plum jobs elsewhere.

21.15 We have evidence that the Trust is having to pay more to attract and retain staff at QEQMH than at WHH and K&CH.

21.16 Many nurses have suggested they will either leave the NHS and go private or leave nursing altogether rather than commute or move.

21.17 In conclusion, we believe that QEQMH would become an enormous hospital which has cost a fortune to build and which would be impossible to staff. Thanet patients requiring specialist services would have to travel at least twice as far to access those services than at present.
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Kent & Canterbury Hospital

22.1 The effect on Canterbury patients would be profound.

22.2 About 26,000 of the patients currently treated at K&CH's A&E department would have to travel to Margate (see above). Of these are tiny but significant proportion with life threatening conditions such as coronary, major trauma, stroke etc, would either not be alive on arrival or have their outcomes severely compromised. This is fact, not conjecture.

22.3 Three of the options would also see elective activity cut by half (around 3000 per year), requiring patients and of course their visitors to travel 18 miles to QEQMH or WHH with the resultant effect on the transport infrastructure.

22.4 The effect on day case treatments and outpatient clinics/consultancies is less clear. EKHT/EKHA suggest that the vast majority of this work would continue to be done at K&CH. Whether this would be sustainable in the long term, we doubt, due to the distances between hospitals and the loss of time involved with senior clinical staff having to undertake frequent 1-2 hour round trips between sites.

22.5 For example, when Crawley's maternity department closed, it had been planned that ante-natal clinics were to be maintained. However, in practice it very quickly transpired that the staff who were supposed to be running the ante-natal clinics were actually elsewhere delivering babies.

22.6 The MHSiEK consultation is manifesting an unfortunate effect on clinical department heads at K&CH. We are told that some have taken a defeatist stance and have ceased to care what happens; but others are positioning themselves to salvage as much of their own departments as they can, even at the expense of others.
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William Harvey Hospital

23.1 Mark Outhwaite (Chief Executive of EKHA) has never made any secret of his belief that within a decade or so, there will only be one acute hospital in East Kent - and that will be WHH.

23.2 WHH could of course be viewed as the overall winner. All gain and no pain.

23.3 However it is beginning to dawn on clinical staff there that even with the amount of expansion proposed, WHH would be woefully inadequate. With virtually all specialisms planned to move there, and they also undertook (say) a quarter of A&E work, a quarter of elective work, increased cancer services, pathology, haematology etc, there would quite simply be massively inadequate capacity.

23.4 We understand that WHH has recently refused to accept the centralisation of haematology because it would require a 22 bed unit and they do not have the space. We understand that when it was suggested to the Clinical Director that Haematology should stay at Canterbury, she said 'what a good idea, we hadn't thought of that!'

23.5 There is a 21 acre field adjacent to the hospital which would allow for virtually unlimited expansion. The kind of facility envisaged in the long term would require WHH to virtually double in size. But at what cost? The outline budgets shown make no allowance for such a massive expansion, and in any case, as we have discussed above, we believe that the QEQMH development would probably take considerably more than the entire budget.
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East Kent Profile

24.1 Any service organisation, private or public can only succeed if it gauges the level of future demand and thus the level of services necessary to satisfy that demand. It follows that two pieces of information are vitally important. First, a true understanding of current levels of activity and second, a realistic projection of growth in that demand.

Current demand.

24.2 Although EKHT/EKHA make copious amounts of data available, it is often not the kind of data necessary to build a true picture of current activity. For example, all activity is gauged by FCEs (Finalised Consultant Episodes) rather than by numbers of patients. One patient could generate one FCE or ten depending on the complexity of their problem and the number of consultants they see. It is therefore almost impossible to enumerate the number of patients who are actually being treated.

24.3 When accused of having incorrect population figures, EKHA has frequently told us that it is not the finite figure which is critical but the change year on year. Which ever way it is viewed, the figures contained in MHSiEK are dramatically and dangerously inaccurate.

24.4 MHSiEK claims the current population of East Kent to be 614,576. The correct figure (according to KCC and the Office of National Statistics) is 618,513. Though the difference is not significant, the very fact that such a simple piece of research is incorrect must cast doubt on all other assumptions.

24.5 It is possible that EKHA/EKHT is unsure of how much of Swale is within EKHA boundaries. We have had this confirmed by the House of Commons library. For future reference, the wards included are Abbey, Davington Priory, St Ann's, Watling, Boughton, Courtney, East Downs and Teynham and Lynsted.

Growth.

24.6 What is far more significant is their projections for the growth of the population. They anticipate a growth rate of 2.4% over ten years resulting in a population of 633,500 in 2011. In fact the average annual growth since 1996 has been 0.91%.

24.7 If this trend continues (and it is more likely to rise than to fall) this would translate into a growth rate of 9.48% over ten years with a total of 683,300. A difference of 50,000 to MHSiEK - which is massively significant and shows that the projected level of service demand is likely to be woefully inadequate.

24.8 And a highly dangerous irresponsible under-estimation of the likely level of future demand on services.

24.9 The figures are based on ONS mid-year 2000 estimates. These show that Ashford (1.49%) and Canterbury (1.21%) to be growing at a much faster rate than all other areas. Thanet actually saw a reduction of 0.05%. ONS projects a 10 year growth rate of 8.3%, however KCC tell us that they know this is inaccurate and it will be revised upwards later this year.

24.10 The figures take no account of SERPLAN which would push the Ashford annual growth rate up by approx 2%.

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	1996	1997	% change	1998	% change	1999	% change	2000	% change	5 year % average
ASHFORD	97900	99200	1.33	99900	0.71	102177	2.28	103698	1.49	1.45
CANTERBURY	136500	138600	1.54	139300	0.51	141261	1.41	143218	1.39	1.21
DOVER	107400	107800	0.37	108700	0.83	109426	0.67	110261	0.76	0.66
SHEPWAY	98700	99300	0.61	99800	0.50	101443	1.65	102612	1.15	0.98
SWALE	30517	30725	0.68	30802	0.25	31085	0.92	31100	0.05	0.47
THANET	125500	126600	0.88	126700	0.08	127685	0.78	127624	-0.05	0.42
TOTAL	596517	602225	0.96	605202	0.49	613077	1.30	618513	0.89	0.91
(source ONS/KCC)

24.11 DETR data includes 'enhanced population' which takes account of daily inflow of people who are not registered as residents and outflow of those who are. These are significant because they take account of tourists, students, travellers, immigrants and others.

24.12 It is likely that these figures give a more realistic picture of East Kent's population for whose healthcare the Trust is responsible.

24.13 The mid-2000 figures are as follows:

ASHFORD 104,769
CANTERBURY 147,953
DOVER 114,070
SHEPWAY 105,199
SWALE 31,062* adjusted for EKHA boundaries
THANET 130,064
TOTAL 633,117

24.14 Although it is convenient to treat each geographical area as if in isolation, there is in fact massive cross-over. For example many residents from the eastern side of Shepway look to Canterbury as either the closest/most accessible or their hospital of choice. The same is true of the A2 corridor and outlying villages in Dover, and the western end of Thanet. Similarly QEQMH is more accessible to some residents on the far eastern side of Canterbury. So far as we are aware no detailed research into this issue has ever been undertaken.

24.15 The following is thus an educated 'guestimate' of cross-over split - by % and figures:

	ASHFORD	CANTERBURY	DOVER	SHEPWAY	SWALE	THANET	TOTAL	%
ASHFORD	95	0	60	75	0	0	241628	39
CANTERBURY	0	90	25	25	100	15	232358	37.8
THANET	0	10	15	0	0	85	139341	22.7
TOTAL							613327*
* The difference being the 5% of Ashford residents who use West Kent. top

The Elderly

25.1 One of the principal planks in EKHT/EKHAÕs argument has been the distribution of the elderly throughout East Kent. Whilst it is true that Thanet has a slightly greater proportion of elderly people, numerically it has almost exactly the same number as Canterbury (28,100 against 27,900).

25.2 It is also believed that because a much higher proportion of Thanet's elderly are in residential homes or under supervised care that their health service requirements are less demanding than those living on their own or in less accessible areas.

18.3 Over 65's represent 18.97% of the overall population - 3.47% higher than the national average.

21.4 It should be noted that the question of access and increased travelling affects the old more than any other group.

21.5 Proportionally they are more reliant on public transport because less drive; their outcomes are more reliant on morale boosting, spirit raising visits from relatives, without whom there is a proven increase in ALOS; the old are far more prone to contracting infections and other illnesses in hospital and have a higher readmission rate; and the old are more likely to be accused of 'bed-blocking' because of their dependence on others.
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Deprivation

26.1 Another major feature of EKHT/EKHA's rationale has been that Thanet is considerably more deprived than other parts of East Kent - which it is. However to put this in context, according to DETR, Thanet is less deprived than, for example, Westminster, Chelsea and Brighton.

26.2 The reason why deprivation is a significant factor in projecting healthcare demand is the assumption (as is true in most other parts of the country) that deprivation leads to greater morbidity and mortality and consequently greater use of healthcare services.

26.3 This assumption is simply not the case in Thanet. The DETR's Standard Assessment Indicator Data shows that Thanet's mortality and morbidity ratios are not significantly different to other parts of East Kent in spite of its dramatically higher deprivation ratio. Comparison between Deprivation, morbidity and mortality by area Source: DETR SSA indicator data. Deprivation based on District Service Index
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Current Position

27.1 When CHEK was established in January 1999, the principal raison d'etre was to fight a major re-configuration which appeared largely unnecessary. The health service in East Kent was running relatively smoothly. The hospitals (or two of them - K&CH and WHH at least) were above average in comparison to national performance indicators, the merging of the three Trusts was to go smoother than some had predicted, and apart from the prospect of 'Tomorrow's Healthcare', there seemed to be no major problems. It was a case of 'If it ain't broke don't fix it', because that's how the situation was perceived at that time.

27.2 Sadly that is not the situation now. By virtually every meaningful criterion, healthcare delivery has deteriorated over the last 18 months. Deteriorated to a point where there are anything up to 100 patients on trolleys in A&E corridors waiting for beds, sometimes for as long as two/three days; where waiting lists and waiting times have lengthened; where elective operations are frequently cancelled; where staff morale is at an incredibly low ebb and where standards of hygiene and cleanliness are appalling and infections such as MRSA are rife. Headlines, such as that in the Daily Mail on Nov 14th 2000 describing conditions as 'third world' have become increasingly frequent.

27.3 Why has the situation deteriorated to such an extent and so quickly? There is one issue, more than any other, which seems to have been the catalyst - and that was the decision to close Nunnery Fields (a Healthcare of the Older Person unit, specialising in stroke victims, close to K&CH) several years earlier than was originally planned. There was only one reason for that decision and that was money. Everyone accepts that the Nunnery Fields building was in poor condition and inappropriate for its use, and that it should have closed years ago. But to attempt to squeeze its facilities into the K&CH before adequate room had been vacated for them has proved to be desperately ill advised.

27.4 There are only 72 HCOOP beds at the K&CH when there were 93 at Nunnery Fields; although extra beds have been created at WHH and QEQMH (however not as many as planned), the move has resulted in the loss of acute beds at K&CH at a time when there is a desperate and proven on-going shortage of acute beds. In the light of the proposed Nunnery Fields acute bed capacity become the bete noir.

27.5 At about this time, a motion was passed by the Medical Staff Committee (the association which includes every doctor in the Trust) begging the Trust to create more capacity; 2 senior anaesthetists begged the Trust to create more capacity; a deputation of 15 senior consultants begged the Trust to postpone the closure and create more capacity, 128 junior doctors wrote a letter begging the Trust to postpone the closure; Most of the surgical residents wrote to the Trust begging them to postpone the closure and create more capacity. All their pleas were ignored in the face of 'financial necessity'.

27.6 In Nov 2000 the Trust commissioned a Risk Assessment from Healthcare Risk Resources International. The Report was delivered in December. The report was generally less than flattering, but about emergency services it was absolutely damning (Appendix 4). It was not until CHEK was leaked a copy in March that the Trust acknowledged the existence of the report and asked senior staff to prepare a plan to counter the problems identified. A remedial plan was presented at the April board meeting, with strict instructions that progress was to be closely monitored. Whilst some progress has been made, it is conspicuously lacking in the A&E departments where the risks were deemed to be critical.

27.7 There have various other major initiatives by the Trust to tackle the crisis of under-capacity and emergency pressures (though EKHA's figures actually show that A&E attendances were 20% lower in 2001 than in 2000). It is our opinion that managers are highly adept at producing documents and theorising about solutions, excellent at presenting them at meetings, but woefully incapable of implementing them.

27.8 Communication between management and staff has been virtually non-existent until recently. For example a group of junior doctors from one of the A&Es who we spoke to had never even heard the name of their Care Group Director, let alone met her. In fact they had never knowingly seen any member of the board apart from the Chairman and one NED.

27.9 Between Nov 2001 and Jan 2002, the Commission for Health Improvement (CHI) undertook a rigorous inspection of all 4 East Kent sites. Whilst the report will not be published until mid-March, we understand that the inspectors have made it known that East Kent is the worst Trust they have visited and have used words such as 'appalling' and 'dire' to describe the situation.

27.10 The Winter & Emergency Services Team (WEST) also visited East Kent in Jan 2002 and were, we understand, similarly appalled.

In closing...

We hope that the above has demonstrated that CHEK takes an objective, evidence-based view of the facts - and sees the big picture as well as the minutiae. We hope that the document shows that our concerns are for all East Kent patients, not just those from Canterbury (which is a frequent accusation). It is our objective to ensure that the prime beneficiaries of any 'modernisation' are patients and the quality, range and access of their healthcare. And that change does not happen for the benefit and convenience of inept or lazy management.
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To note:

The Cancer Plan

The challenge of cancer

1. More than one in three people in England will develop cancer at some stage in their lives. One in four will die of cancer. This means that, every year, over 200,000 people are diagnosed with cancer, and around 120,000 people die from cancer. So better prevention of cancer, better detection of cancer, and better treatment and care, matter to us all.

2. The Cancer Plan sets out the first comprehensive national cancer programme for England. It has four aims:
* to save more lives
* to ensure people with cancer get the right professional support and care as well as the best treatments
* to tackle the inequalities in health that mean unskilled workers are twice as likely to die from cancer as professionals
* to build for the future through investment in the cancer workforce, through strong research and through preparation for the genetics revolution, so that the NHS never falls behind in cancer care again.

For the first time this plan provides a comprehensive strategy for bringing together prevention, screening, diagnosis, treatment and care for cancer and the investment needed to deliver these services in terms of improved staffing, equipment, drugs, treatments and information systems.

The Cancer Plan

3. The NHS Plan, published in July, set out the government's plans for investment and reform right across the NHS, to develop a health service for the 21st century, offering fast, convenient, high quality care, with patients at the centre. The Plan identified cancer services as a high priority to benefit from these improvements. It promised progress on cancer prevention, on research and on improved access to services. This Cancer Plan now sets out how these improvements will be introduced. The Cancer Plan shows how cancer services will benefit from increased investment: how investment in staff will respond to shortages in key specialities and enable services to expand; and how investment in new updated equipment will enable faster access to diagnosis and treatment.

4. And the Plan sets out how this investment will need to be accompanied by reform: through new ways of working to streamline cancer services around the needs of the patient; through extending the roles of radiographers, nurses and other staff; and through guidance to ensure high standards of treatment and care are in place right across the country.

5. The Cancer Plan is a practical document for the NHS and its partners, setting out the actions and milestones that will deliver the fastest improvement in cancer services anywhere in Europe over the next five years. By 2010, our five year survival rates for cancer will compare with the best in Europe.

6. At the heart of the Plan are three new commitments. These will be:
¥ In addition to the existing Smoking Kills target of reducing smoking in adults from 28% to 24% by 2010, new national and local targets to address the gap between socio-economic groups in smoking rates and the resulting risks of cancer and heart disease:
* we shall reduce smoking rates among manual groups from 32% in 1998 to 26% by 2010, so that we can narrow the health gap
* we shall set local targets making explicit what this means for the 20 health authorities with the highest smoking rates.

* New goals and targets to reduce waiting times for diagnosis and treatment so that:
* the ultimate goal is that no one should wait longer than one month from an urgent referral for suspected cancer to the beginning of treatment except for a good clinical reason or through patient choice.
* for some uncommon cancers like acute leukaemia, children's cancers and testicular cancer, this is what most patients already experience.
* for other cancers this will take time to achieve, so we will set milestones along the way:
* by 2005 there will be a maximum one month wait from diagnosis to treatment for all cancers
* by 2005 there will be a maximum two month wait from urgent GP referral to treatment for all cancers.

* An extra £50 million NHS investment a year by 2004 in hospices and specialist palliative care, to improve access to these services across the country. For the first time ever, NHS investment in specialist palliative care services will match that of the voluntary sector.

7. These new commitments will strengthen the fight to prevent cancer; ensure that all who need it are guaranteed fast diagnosis and treatment; and provide increased support for people living with cancer right across the country.
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The NHS Plan

Core principles are:
1. The NHS will provide a universal service for all based on clinical need, not ability to pay.
2. The NHS will provide a comprehensive range of services
3. The NHS will shape its services around the needs and preferences of individual patients, their families and their carers
4. The NHS will respond to different needs of different populations
5. The NHS will work continuously to improve quality services and to minimise errors
6. The NHS will support and value its staff
7. Public funds for healthcare will be devoted solely to NHS patients.
8. The NHS will work together with others to ensure a seamless service for patients.
9. The NHS will help keep people healthy and work to reduce health inequalities
10. The NHS will respect the confidentiality of individual patients and provide open access to information about services, treatment and performance

We find it very difficult to reconcile these core principles with a proposal which will disadvantage almost 40% of East Kent patients, reduce the range of its services, allow patients less choice, create 'seams' where seams did not exist, and provide a less equal service within its boundaries.
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HImPs

Principal aims
* Reduce by 20% premature deaths for people under 75 years who have Cancer;
* Reduce by 20% premature deaths for people under 75 years who have heart disease or stroke;
* Reduce by 20% deaths due to accidents in all age groups. Again it is impossible to reconcile these laudable objectives with a plan that will
* drastically reduce the range and accessibility of cancer services; *reduce the accessibility of emergency services for almost 40% of the region;
* reduce the accessibility of major trauma services for almost 40% of the region.
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