Lewisham Hospital gets its case argued

[LondonMix]

I'm not sure what those opposing the closure are trying to say exactly. Certain south east London hospitals have been very poorly managed (though not Lewisham). The idea is that they will be taken over by well functioning hospitals. The PFI contracts will be funded directly by the Department for Health so that the legacy of them will no longer weigh down the hospitals and the new management allowing for a clean start. The changes proposed at Lewisham have to do with the assertion in the report that A&E's are over supplied in SE London while other services (the non-complex surgery unit) are missing. Given the geographic / services etc, the analysis concludes these changes are best for overall service by numerous measures. I'm not saying that A&E's are over supplied as I have no idea (but in a previous thread a few others who work for the NHS have said they agree with this assertion). The precedent in my view (if it does genuinely achieve its goals) isn't a bad one.

Regarding the sickle-cell post. I'm surprised that writer predicts the replacement of Lewisham's A&E with a UCC will have such dire consequences for those with sickle cell. The UCC should be able to deal with most issues of this chronic genetic disorder and I'd be surprised if the other hospitals in SE London weren't able to deal with major complications (stroke / serious infection etc) appropriately. If so, training about sickle-cell would appear to be a more sensible solution than keeping an A&E open specifically to deal with sickle cell.

Strafer, I agree those in a more affluent area might have more political weight to stop a positive change and that they (like anyone) would fight to keep an A&E in their area even if there were other A&Es within a safe distance. However, that certainly doesn't mean that good decisions shouldn't be made because at times, certain more affluent areas might have greater ability to stop appropriate action being taken. The changes at Lewisham are either for the best or not.

[Saffron]

Marmora Man Wrote:

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> Saffron Wrote:

> ...

>

> "instead of actually doing what's morally and

> financially necessary" - when there are

> constraints on what is financially possible this

> absolutist position cannot be sustained.

I don't disagree that there are financial constraints. But where we part ways is that I don't believe those constraints either stretch to, or justify, deconstructing Lewisham in any way, particularly under the guise of 'rescuing' poorly performing hospitals.

> The

> report proposes a sensible and rational

> compromise.

Yes, but the report is not god. It's not the only viable solution.

[LondonMix]

What are the other viable options that work as well?

[Saffron]

Use your noodle.

[Marmora Man]

Saffron Wrote:

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> Use your noodle.

If know the answer it's unfair to deny the rest of us, that use logic, analysis and argument to reach a conclusion, the details of your illumination.

[LondonMix]

So the viable alternative is something those who oppose the changes at Lewisham understand but refuse to articulate!

I have been trying to find a credible argument against the closure (that the analysis in the report is wrong on any front / that there is a better alternative etc). If someone who is passionate about this actually has any information like this from a credible source, I'd like to read it. Just because the report reaches certain conclusions doesn't mean that should be the end of the discussion but I do want to engage with actual facts and analysis...

Saffron Wrote:

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> Use your noodle.

[StraferJack]

This debate is making me increasingly uncomfortable

There is a condecension in the "logic and reason" comments I can't abide - as if history has been shaped by logic and reason alone, and not fire in the belly rhetorical types

let's take

"I have been trying to find a credible argument against the closure "

Was anyone on here suggesting it should be closed before the report? No.

So if a report is commissioned and examined, it should be exemplary in it's case

Basically - if an average Joe is waiting 2-3 hours in A&E and there is a cost-saving way of providing a better service then it should be piss-easy to demonstrate. And the average Joe will sign up straight away

I haven't seen that example in any report and certainly not in the Mike Farrar column so eagerly highlighted by some posters.

If you want an example of aspirational, management-speak, meaningless waffle then by all means be inspired by it. There is nothing factual, logical or persuasive in anything he says

But I don't mind being wrong - and it will be easy to prove me wrong. In a year or two you can simply vox pop the happy punters in Lewisham who say "do you know what? I don't know what all the fuss was about?"

This won't happen of course

just as with PFI back in the 90s, opponents are asked to "come up with a better plan" - as if they had a problem in the first place

here is what happens in situations like this (applies to any large org, private, public, whatever)

Costs ARE important. So important that any twonk who comes up with a "bold initiative" is eagerly heard out. The downsides are downplayed, a report is produced and the onus falls on opponets to prevent a fait accompli from happening

If it all goes tits up, enought "other factors" abound and can be blamed

If nothing goes too badly wrong, the success is entirely down to the policy

A large American bank outsources it's IT 10 years ago in the face of strong opposition - logic isn't ALLOWED when decisions are made at this level. BUt it was presented anyway. And dismissed. A short few years later the same bank quietly insourced the same functions, for all the reasons dismissed as "emotive" at the time

this smells

people know it smells

and if they lack access to all of the facts, or the articulacy to persuade others it doesn't make them wrong

[LondonMix]

There already was the realisation that there were too many A&E's I think based on what some who work for the NHS in South London have already said on another thread about this issue (I don't know myself). Nick Triggle, BBC's Health Care correspondent well before this report was published argued the same so it appears to be a well understood problem for some time.

I do know that the people waiting 3 hours at an A&E (usually for urgent but non-critical injuries) are in part waiting that long because they are at an A&E vs and urgent care centre. At urgent care centres (like the one being proposed) people in need of stitches and with broken bones are not constantly being pushed down the queue by more serious emergencies like heart attacks, reducing waiting times for those who aren't critically ill.

This isn't to say that the decision to make the changes at Lewisham is the right one. However, I do think it's important to engage with the actual proposal if you are going to argue against it. Some issues are complex and the right decision isn't always obvious to everyone unfamiliar with all the details and I don't think saying that is condescending. I don't think there is anything insulting or bad about acknowledging that. I actually think its condescending to assume the general public can only understand fire in the belly rhetoric.

[StraferJack]

". I don't think there is anything insulting or bad about acknowledging that. I actually think its condescending to assume the general public can only understand fire in the belly rhetoric."

I never said any such thing about the general public. I said history turned. Quite different

Anyway. Nick Triggle. I should care about his opinion because

A) he is pro privatisation

Or

B ) he presents a compelling case ?

Edited because a capital B and close bracket make a smiley. Tsk

[Marmora Man]

SJ - it's been an open secret in the healthcare community of London that a rationalisation of London services is long, long overdue. Once upon a time there were many small separate health authorities covering London, almost as manay as there were hospitals and most of these hospital came into being organically via local actions of charities, local authorities and local benefactors rather than as part of a "plan for London". The health authorities reduced to became four and then one. Still, the senior management and politicians ran scared of the necessary re-organisation of the hospitals.

Now, admittedly on the back of a financial failure, there is an opportunity to start the needed changes in SE London, similar changes are being debated in NW London (albeit at a lower temperature at present, tho' the debate has had its moments). The three closest hospitals to this postcode are amalgamating into one organisation - Kings, Guys and St Thomas' hospitals will be under the same management soon. Expect changes and consolidation - it's not ignoring peoples choice, its not top down management, it's not cost saving made necessary by Coalition cuts, it's not "stealing" services from the community - it's common sense.

EXAMPLE: Less than 5 years ago most London hospitals provided, via their A&E departments stroke care. Paramedics and Ambulance services were directed to take stroke victims to the nearest A&E. Now there are just 5 specialist stroke units across LOndon. Costs have fallen, expertise has increased and lives are saved on a daily basis by driving to the specialist centre rather than the closest centre.

The loudest argument of the "Supporters of Lewisham Hospital" is proximity - it's a rubbish argument in the healthcare world.

[LondonMix]

No, SJ I'm just saying the report isn't the first time those involved with the NHS (as reporters or staff) seem to have been aware that perhaps there are too many A&Es to be viable in the area. You seemed to suggest that no one new this was a concern before the report in your previous post unless I misunderstood you. I'm not saying that's true- others closer to the NHS on the EDF have. If this isn't true, the argument against changing Lewisham falls apart. That's why I have repeatedly asked about this as this is really the crux of the entire proposal.

If it is true that there are too many A&E's then how you decide which to close has to be done by geography and services-- you can't close a hospital if it meant that a portion of the population would have greater travel times via blue light ambulance than minimum safety guidelines allow. Also, you need to have an appropriate spread of hospitals with certain specialisations like stroke, major trauma.

Anyway, here is the report for anyone who hasn't been able to find it but would like to read it.

http://www.tsa.nhs.uk/sites/default/files/TSA-DRAFT-REPORT-WEB.pdf

[StraferJack]

Too many a and e s for what tho?

And with all due respect to successful treatment of stroke victims, what percentage of a and e admissions is that?

Is there a parallel where a service looks at people queuing out the door and concludes "what we can do to better serve these people is shut up shop?"

Rationalisation is such a vague, aspirational term. Who could disagree

But shutting down a whole hospital with long queues? At leat with firemen there is the argument "well, they spend x % doing nowt so..."

Unless I see doctors, nurses and patients united in support of closures I'm still smelling something more than "rationalisation"

[LondonMix]

The hospital is not closing. The A&E will become and urgent care centre which can treat all non critical (so broken bones but not strokes) issues. 70% of Lewisham's cases are already issues that the proposed 24/7 UCC will be able to deal with. Waiting times at UCCs are shorter than at A&E's for people with non-life threatening issues for the reasons I explained in an earlier post.

[LondonMix]

Also, the idea would be to create a specialist elective surgery (like hip replacement and knee surgeries) unit at Lewisham as part of the changes. Waiting times for these surgeries are currently too high in SE London because when they are housed in a hospital with an A&E the surgeries too often have to be postponed at the last minute due to demands on staff to deal with urgent life-threatening surgeries that arise. By creating a specialist centre at Lewisham (where there will be a UCC but no A&E) serving all of SE London, scheduled surgeries of this type won't be cancelled at the last minute thus reducing waiting times for these procedures across this entire part of London.

[StraferJack]

I understand what the promises are. Does it not bother you that they might not happen?

Not from any ideological viewpoint. But from a "history shows.." perspective

[LondonMix]

It concerns me a great deal which is why I spent 3 hours reading the full report. The decision, before looking into it, struck me as very odd, which is why I decided to try to learn more.

Bad decisions are made by people even with good intentions all the time. All of us, including Kershaw et al, are only human and are entirely fallible. That's why I would like to try to critically assess all of the assumptions. I've tried to find out what I can regarding waiting times at UCCs etc and it appears to hold up but there might be a million and one things I as a non-expert might be overlooking. I would urge everyone to read the report and engage with it. I want what's best for SE London healthcare, whatever that might be.

[civilservant]

I had a quick look at the report (the final version has now been published) and was very surprised to find after all the hoohah in the press that it does NOT recommend that the hospital be closed.

From a quick glance, it's not easy to see exactly what the recommendations are, and I haven't had time to read the report carefully. But overall it paints a picture of a poorly performing trust with serious management and clinical deficiencies delivering very poor value for money. I was also struck by the report's characterisation of primary care in SE London as being consistently below the rest of the country both in terms of access and patient experience - whether this was just about Lewisham wasn't clear.

[LondonMix]

It wasn't about Lewisham, it was about the South London Healthcare Trust. Lewisham delivers a good service but due to its small size is very vulnerable to cost swings as it doesn't have economies of scale. Lewisham's Trust will take over one of the hospitals in the South London Healthcare Trust.

Anyway, the proposal is absolutely not for the hospital to close as you rightly say! Certain services will be reduced and new services will also be added...

[Marmora Man]

SJ:

1. " Unless I see doctors, nurses and patients united in support of closures I'm still smelling something more than "rationalisation" - doctors, nurses and hospital staff are no more selfless when it comes to possible loss of jobs, position or power than union or non union members of a car production line or a chocolate factory. Their opposition to change (NOT closure as LondonMix has pointed out) should be considered with this in mind.

2. I understand what the promises are. Does it not bother you that they might not happen?

Not from any ideological viewpoint. But from a "history shows.." perspective

You're too objective surely to deploy this hackneyed argument against change. You would despise an old Tory like me for putting it forward.

[Alex K]

No discussion above of the pros / cons of withdrawing obstetric surgical coverage from a lying-in ward. The costs of a delayed cesarean section (blue-light ta-tu-ta-tu transfer to tertiary hospital, etc.) are substantial: How much "extra" does lifelong care run for a person who suffered hypoxic / ischaemic brain injury whilst being born? Considered in the lump rather than parcelled out year by year, they might provide an argument for retaining at Lewisham this service.

[LondonMix]

AlexK, the proposal was actually put together with the endorsement and input from various clinicians and the issue you raise is why the maternity services would have to change with the change of the A&E to a UCC. There have been a few options on the table including only a mid-wife led unit dealing with low risk births which is considered clinically safe without full emergency capabilities at the hospital. However, continuing to deal with complex, high-risk births without full emergency capabilities was deemed too risky by the independent clinical panel. Please see extract from the report where this is discussed in detail:

158. There are two options under consideration for draft recommendations relating

to maternity services. In both options ante-natal and post-natal care would be

provided, as now, at all hospital sites and in the community. The option of a

home birth would remain open to women. The two options relate to women

who need to be admitted to hospital during their pregnancy and those women

who need, or wish, to have an obstetric-led delivery. The two options are

whether south east London has four or five hospital sites providing obstetric-led

services:

? The option of 4 hospital sites: King?s College Hospital, Princess Royal

University Hospital, Queen Elizabeth Hospital and St Thomas? Hospital

would all provide obstetric-led births, meaning these services are co-located with full emergency critical care. This co-location was the initial proposal

developed by clinicians and endorsed by the external clinical panel.

However, this option would mean the 4 sites would need to increase

capacity which would require some investment.

? The option of 5 hospital sites: King?s College Hospital, Princess Royal

University Hospital, Queen Elizabeth Hospital, St Thomas? Hospital and

University Hospital Lewisham would all provide obstetric-led births. In this

option University Hospital Lewisham would not have full emergency critical

care co-located with its maternity unit; instead it would have a surgical high

dependency unit (HDU) with obstetric anaesthetists present. This means the

service would only take lower risk obstetric-led births. This option would

provide better access to obstetric-led services in south east London. It

would also provide more resilience to the needs of a growing population.

However, the external clinical panel has expressed some reservations about

the clinical sustainability of this model.

159.There are benefits and risks associated with each of these options (see figure

25). Therefore, the external clinical panel has recommended that further work

is undertaken to examine each option. There are also different views on the

expected population growth and birth forecasts within south east London over

the next 3 ? 10 years. Broader engagement in exploring these options will be

sought through the consultation process. Agreement will be sought on the

number of births forecast so that correct capacity requirements can inform the

work. The outputs of this will be scrutinised by the external clinical panel and a

recommendation will be made by the TSA in the final report in January 2013.

[LondonMix]

To those of you like SJ who believe this was just some Whitehall type proposal totally divorced from medical / clinical considerations please note that clinicians were very involved with coming up with the Kershaw's recommendations:

24. A clinical advisory group ? composed of clinicians from all NHS organisations in

south east London, and a patient and public advisory group ? formed of

representatives of Local Involvement Networks and patient councils ? have fed

directly into a TSA advisory group.

25. An external clinical panel has provided additional scrutiny to the development

of the draft recommendations. The panel was assembled to act as a ?critical

friend?: an independent group that fully understands the context of the work and

can provide constructive criticism and ask provocative questions. In carrying

out its function, the panel has provided the programme with valuable insights,

based on independent clinical expertise. It has played a key role in challenging

the development of draft recommendations, for example, to emergency and

maternity services and is supportive of the proposals and options in this report.

[civilservant]

LM are you involved in the Lewisham proposals? You sound very knowledgeable about them

[LondonMix]

No, not at all. I really don't know very much as I don't know much about healthcare or the NHS. I have read the report in detail is all and tried to follow the protests in the press. The report itself is very detailed (it took me 3 hours to get through). Because Kings is involved in the reorganisation (its absorbing one of the hospitals), I wanted to understand what was happening to the greatest degree possible.

[Saffron]

LondonMix Wrote:

-------------------------------------------------------

> So the viable alternative is something those who

> oppose the changes at Lewisham understand but

> refuse to articulate!

>

> I have been trying to find a credible argument

> against the closure (that the analysis in the

> report is wrong on any front / that there is a

> better alternative etc). If someone who is

> passionate about this actually has any information

> like this from a credible source, I'd like to read

> it. Just because the report reaches certain

> conclusions doesn't mean that should be the end of

> the discussion but I do want to engage with actual

> facts and analysis...

>

> Saffron Wrote:

> --------------------------------------------------

> -----

> > Use your noodle.

Nope, just not going to waste anymore time putting it on a spoon for you, so that it can be spat back in my face like a weanling.