NHS for Sale: Myths, Lies & Deception (29 page)

The College of Emergency Medicine has gone further and stated clearly that claims by Darzi, McKinsey and NHS London that 60 per cent of A&E attenders could be diverted to primary care are ‘fiction’.
¹⁰
No new evidence has emerged since then to challenge this judgment, so it appears that any plans for A&E closures based on McKinsey’s assumptions will be a wild gamble, based on wishful thinking rather than serious evidence-based proposals.

If the aim is to save money, why do so many reconfigurations revolve around the idea of closing an A&E? It’s not because
there are big savings to be made by closing A&E. When McKinsey produced their report for NHS London in 2009,
¹¹
outlining savings proposals, their figures showed that spending on A&E (seeing 3.8m patients) was just £300m out of £11.3bn – just 2.6 per cent of London’s health budget; so even closing
all
A&E services would only make a small impact on the projected shortfall.

A&E services are incredibly ‘cheap’ to run, because the NHS tariff is so close to the actual cost, leaving hospital bosses no margin to cover any extra costs of agency staff, overtime and the losses incurred from the treatment of ‘excess’ patients above the 2009 caseload (whose care is paid at just 30 per cent of tariff costs). This means all of the financial pressure lands not on the commissioner but on the trust.

So the direct impact of closing an A&E – especially if it is replaced by alternative services in the community, or requires expansion of other A&E units in neighbouring hospitals – is in itself a marginal cost saving.
*
Its attraction for NHS bureaucrats is that it opens up more possibilities for cutbacks and closures in the longer term.

Almost every closure of an acute hospital since the late 1970s has begun with the closure of A&E. It marks the start of a tried and tested sequence of events, and in itself helps to create a phony ‘clinical’ justification for the continued process of downsizing and then closing a busy local hospital. In
Chapter 6
we quoted extracts from the spoof
Briefing for Cynical Commissioning Groups
on how to ‘get away with’ hospital closures drawn up by campaign group Health
Emergency. It is drawn from numerous real-life consultations, and emphasises the longer-term view when it advises cynical commissioners:

Make a strong play for your credentials as upholding ‘safety’ and improving patient care. Not only does this divert from what you are actually doing, but the ‘safety’ card can prove very handy as an excuse for the second wave of cuts that will inevitably follow on once the first wave is in place.

Having reduced a site to elective services only and removed ITU (Intensive Therapy/Treatment Unit) etc., you can pick your time to argue (obviously with regret) that it can’t be properly staffed, and more services need to close – perhaps ‘temporarily,’ and then permanently … for ‘safety’ reasons. This way you can get away with closures without any consultation at all.
¹²

On this, the spoof accurately mirrors the way this has all been done before in real life.

• First A&E opening hours are cut back, and trauma services are removed, reducing services to out of hours medical emergencies.
  
• Then maternity services are cut back and then closed.
  
• Piece by piece the key elements that go in to making a district general hospital are hacked away, with each block removed from the package triggering others to fall – like some giant game of NHS Jenga.
  
• With A&E goes paediatrics, ITU, High Dependency Units and Coronary Care.
  
• With maternity goes women’s care.
  
• With the loss of trauma goes orthopaedics.
  
• Emergency surgery is then pronounced ‘unsafe’ or ‘unsustainable’ and removed.
  
• Each element takes a range of supporting services with it, until the hospital is allowed to wither away, and each cutback also makes it harder to recruit medical staff and qualified nurses, opening up arguments that further cuts are required because staffing levels are inadequate.
  

To cap it all, trendy arguments are wheeled out by the King’s Fund, McKinsey and other hired hands suggesting that new ‘settings’ can deliver services more efficiently and effectively than hospitals. The only snag is that these ‘settings’ and services exist only on paper. The vague promises of services ‘closer to home’ wind up with the actual closure of hospitals that local people value and depend upon, but nothing to replace them. The alternative provision of care in UCCs or GP surgeries is not a lot cheaper – and for those who have more serious health problems, nowhere near as good.

From start to finish, even though the whole cynical process is dressed up in ‘clinical’ arguments, the long term goal is making savings – whether from reductions in patient care, lost jobs, reduced capital costs, or even sale of ‘spare’ land and buildings. Another plus factor for commissioners is that a threat to an A&E will also draw almost all the attention of local public campaigning and press coverage, letting local Clinical Commissioning Group (CCGs) get on with other cuts to services such as mental health and older people’s services with relatively little disruption.

The origin of the TSA’s wild guess of 77 per cent of A&E patients to be treated in a standalone Lewisham UCC or in ‘the community’ is a bit of a mystery. Back in 2007, Lord Darzi’s report on London started the rot with the proposal (set out in the supporting McKinsey-researched Technical Paper)
¹³
for 50 per cent of the capital’s A&E attenders to be shifted into polyclinics. This figure was then arbitrarily jacked up to 60 per cent by NHS London’s Planning Guidance. The source of Darzi’s original assumptions or of these revised figures has not been publicised. There has been no proper scrutiny of the evidence base or the methodology used, yet these figures have been taken as a starting point for many subsequent plans in London and elsewhere.

According to the spoof guide for
Cynical Commissioning Groups:

A reconfiguration needs more than just closures: it needs a ready supply of dodgy plans appearing to cut costs, improve ‘productivity’ and ‘focus resources’. One ready source is the McKinsey report from 2009 which first mapped out ways to ‘save’ £20bn from the NHS – through measures including the rationing or exclusion of elective treatments including hip and knee replacements and cataract operations … or cutting doctors’ consultation times…. Other old favourites include citing completely imaginary travel times to more distant hospitals.
¹⁴

NHS London claims to have partly rested its case for reducing A&E services (and relying instead on UCCs, primary care and community services) on a report researched by PA Consulting, published in 2008. They clearly assumed nobody
would check what that report really said. However the
Study of Unscheduled Care in 6 Primary Care Trusts Central Report
¹⁵
offers little support for those seeking to inflate the numbers of minor cases in A&E. It is a detailed and nuanced 180-page study of caseload in six varied London primary care trusts, which is repeatedly at pains to stress the potential for bias in its findings and the complexity of the issues it is analysing. It makes much more limited claims than NHS London on the level of ‘inappropriate’ attendances at A&E.

Another report,
Primary Care and Emergency Departments
commissioned from the Primary Care Foundation by the Department of Health in 2010, questioned the assumptions on how many A&E attenders could be adequately treated in a primary care setting.
¹⁶
The Department of Health’s specific brief was to ‘provide a viable estimate of the number of patients who attend emergency department with conditions that could be dealt with elsewhere in primary care’.
¹⁶
Yet even from this starting point the researchers found that relatively few patients attending hospital Accident and Emergency departments could be classified as needing only primary care – suggesting that NHS London had drastically overstated the case for shifting work out of hospital A&E. The 102-page report specifically took issue with ‘widespread assumptions that up to 60 per cent of patients could be diverted to GPs or primary care nurses’, and argued that the real figure is as low as 10-30 per cent.
¹⁷

Significantly the extensive study of patients in actual A&E departments also found no evidence that providing primary care in Emergency Departments ‘could tackle rising costs or help to avoid unnecessary admissions’. The authors of the report also question the financial case for diverting patients from A&E, arguing that ‘cost benefits may exist, but the
evidence is weak.’
¹⁸

Among Health Emergency’s spoof suggestions, all drawn from real life ‘consultations’, is the advice to:

Ignore any questions on embarrassing figures and issues that might discredit your argument – such as figures showing the continued rise in emergency admissions and referrals, the pressure on hospital beds, the spiralling workload on over-stressed staff, the levels of deprivation and other specific needs of a local population, etc.

Just ignore them. Ministers won’t hear them, and will back you anyway.

The Trust Special Administrator followed this approach to insist that 77 per cent of patients in Lewisham could be handled through a free-standing UCC or in community based services. This same misleading claim helped to secure the plan a spurious clean bill of health in the
Health Equalities Impact Assessment
drawn up for the TSA by Deloitte. After reluctantly admitting that Lewisham’s population suffers high levels of deprivation, and that this deprived population would suffer if journey times to access treatment were increased. Deloitte countered this by using the spurious 77 per cent figure:

As Lewisham has a number of deprived wards, this impact will need to be considered in greater detail. However it is estimated that between 70 per cent and 80 per cent of patients currently receiving treatment at University Hospital Lewisham (UHL) A&E could be treated at its urgent care centre, potentially abating the scale of this impact.
¹⁹

Since clinicians’ views and evidence are so blatantly disregarded in this plan to downgrade a busy A&E department (and similar plans elsewhere), what grounds are there for believing the claim that such plans are ‘clinically led’ rather than driven by concerns over balance sheets?

In Bedfordshire, too, similar arguments have been wheeled out by a Clinical Commissioning Group seeking to drive a rationalisation of services in Bedford and Milton Keynes. Their plans,
²⁰
which were contested by a strong local campaign, have since been shelved until after the election, but not yet abandoned. They looked to scale down hospital care in one trust or both – suggesting that local people might as readily use other ‘nearby’ hospitals – all of them between 20 and 50 miles away.

The proposals were backed up by a series of abstract assertions – for example that 20 per cent of people who go to a GP turn out to have ‘self-treatable minor ailments’ – without explaining how people are supposed to diagnose this themselves, and distinguish their ‘minor ailments’ from early symptoms of more serious problems. Nor do they show how this questionable statistic relates to their plans to scale down hospital services.

Bedfordshire health chiefs also argue that 50 per cent of 999 ambulance calls ‘could be managed at the scene’. This assumes that sufficient properly trained and equipped paramedics have the time and facilities to do so. However there is no explanation of why they don’t do this now, or what proportion of cases are already managed at the scene.

Apparently a million emergency hospital admissions were ‘considered avoidable’ by somebody or other in 2012-13.
Again no explanation is offered on where these figures came from, how they were derived, or how this claim squares with other very different findings. What alternative services outside hospital would need to be in place to avoid these emergency admissions?

In a ludicrous contradiction, the same set of figures, also quoted by Bedfordshire and Milton Keynes health managers, shows that just 4 per cent (960,000) of the 24 million calls to NHS 111 emergency lines could be resolved on the phone. It seems that not all callers are just timewasters after all.

We don’t have to look very far to find the financial pressures behind the reconfiguration plans. NHS London’s
Integrated Strategic Plan 2010-15,
published in January 2010, just months before the coalition government took office, warned
²¹
that urgent action was needed to bridge a potential ‘funding shortfall of between £3.8bn and £5.1bn per year in the capital on a recurrent basis’ by 2016. These figures are strikingly similar to the projections of NHS England’s London region looking forward from 2013. This is clearly the starting point for the subsequent plans for huge cost savings – including reconfiguration. These savings were part of a massive programme of cuts throughout England: the
Health Service Journal
estimated the total of hospital trusts’ planned ‘cash savings’ for 2012-13 at £2.35bn.
²²

In north-west London, too, it’s clear that the unspoken driver is in fact the prospect of a £1bn cash gap between resources and local need for health care. To bridge at least some of this gap the PCTs in the eight boroughs of northwest London organised together as ‘NHS North West London’ (NHSNWL) in 2010-11, and drew up plans to slash £314m from
north-west London hospital budgets over three years, as well as cutting £297m from health commissioning budgets.
²³

The CCGs, which have taken over the plans from their predecessor the primary care trusts (PCTs), also want to open up the health budgets of north-west London to ‘Any Qualified Provider’, to create the kind of competitive market in health care outlined in the Health and Social Care Act. To do this means further undermining the financial viability of established NHS providers, and reducing their capacity. And new providers could only help CCGs save money while also pocketing a profit if they are encouraged to compete on price, and encouraged to offer a ‘cheap and cheerful’ downgraded service with reduced reliance on better qualified staff.