A Picture Of Health consultation

Written by Lewisham Liberal Democrat councillor group and published in A Picture Of Health consultation on Mon 7th Apr 2008

There are many issues and concerns raised by the consultation and business case.

It should be noted that many residents contact us to say they either did not received the consultation document or that they found the format and presentation so difficult it discouraged them from responding. However, I think it is easier for us to concentrate our concerns into three areas. Each area raises concerns about the viability of A Picture of Health and we formally ask the JPCT to reject the 3 options presented and reconsider the shape of our local health services.

APOH will lead to insufficient capacity to meet the demand for services

Our main concern is health care for the residents that we represent in Lewisham. We are therefore particularly concerned about the impact on A&E Services, Maternity and Paediatrics services. There is evidence that the current levels of provision struggle to meet the existing demand. We know that our area faces demographic changes, the official figure is that the borough of Lewisham has a population of 250,000, which we believe is an under-estimation and there is a number of people living locally and needing health services but are "hidden" from official data. If the GLA prediction of growth by 35,000 is correct, there will be growth of over 15%, again we are concerned that this is an under-estimation of the actual population growth. In local authority terms this population increase will lead to between 2 to 3 wards being added to the borough, in health service terms it will clearly place an extra pressure on local services.

Currently there are four A&E departments within the area; their average rate of breaches of the 4 hour standard exceeds the London wide average. Options 1 & 3 in APOH suggests the closure of University Hospital Lewisham, the busiest A&E department within the cohort, whilst keeping Princess Royal Hospital which has breached 34 weeks out of the last 52 (between March 2007 & March 2008) and Queen Elizabeth Hospital which has breached 9 weeks out of 16 weeks this winter (18th Nov 2007 -2nd March 2008). The Government tells us that patients should not have to wait more than four hours before being seen at an A&E department, our local hospitals are consistently failing to achieve this. There should not be any closures of A&E departments until hospitals can demonstrate they can cope with present workloads.

APOH argues that visits to the A&E departments can be dramatically cut, although various strategies over the last decade to achieve this have failed (It is interesting to note, for example the NHS Direct aims to reduce visits to GPs and A&E departments yet often the advice is to "do this….then go to A&E to be on the safe side") There is insufficient evidence to suggest that public will be well enough educated to achieve the reduction in attendances in the timescale set by APOH. It states that it would speed up the journey through A&E for those with more serious conditions, implying those with less serious conditions will not be treated within the 4 hour standard. Few sites for A&E departments does not equate with greater efficiency and with the greater travelling times, many patients will find they have a longer period between an incident and treatment. We are not convinced that closing two A&E departments, including the busiest (currently getting 18,000 attendances per week); even with the additional capital investment (set at £10 million for the implementation for the whole of the APOH) will leave the area with sufficient capacity. It is noted that Kings College Hospital has predicted it will have considerable extra A&E attendances, which have not been factored into APOH.

Changes in the way that London Ambulance Services will deal with emergency calls have emerged during the period of consultation for APOH. It is difficult to have confidence in the accuracy of figures for reducing A&E attendances when so many different proposals are being considered separately but at the same time. At present LAS do not have the capacity to implement APOH, they will need to invest in additional vehicles and their paramedics will have to undergo extra training. It is therefore a serious concern as to whether they can rise to the challenge set by APOH. It is a grave cause of alarm to us that journey times from most parts of Lewisham to an A&E department, if options 1 & 3 are pursued will be far longer. These longer journey times will inevitably lead to a deterioration in patient care and may risk the lives of some patients.

The same pressures of capacity for A&E services exist for maternity services within the borough of Lewisham. The projected population growth will put extra pressure on fertility rates locally; Lewisham already has amongst the highest fertility rates in the UK. London is has experienced the fastest increase in birth rates in England since 2000 and the evidence suggests this trend will continue in Lewisham. Closure of maternity services at University Hospital Lewisham will leave about 4,000 mothers each year looking for access to alternative maternity facilities.

There is an assumption in APOH that homebirths will increase to 7%, we do not believe this achievable in Lewisham (currently homebirths account for less than 2% of Lewisham births). National maternity statistics indicate that around 50% of pregnant women will require some form of medical care during delivery and there must be adequate provision available in Lewisham to meet these needs. APOH has failed to identify the impact on services to the North of the borough. As with A&E services Kings College Hospital have predicted an extra impact on their maternity facilities and Guys/St Thomas will also be affected. The APOH team do not appear to have undertaken sufficient work or research in this area prior the consultation.

APOH fails to address the impact on health inequalities

The APOH project team has failed to produce their integrated impact assessment during the consultation period, this suggests that absolutely no consideration has been given to the impact on existing health inequalities and how these are should be addressed. Indeed several options will exacerbate the headline facts - people do not live as long in the north part of the Outer South East London( OSEL) sub region and peri-natal and incidents of still births are higher in the north part. Each PCT within the OSEL area includes addressing health inequalities among their priorities and there is no evidence that it is a priority within APOH. There are areas of greater deprivation in Lewisham than in the other parts of the area covered by APOH, this in many cases leads to greater need for hospital services. This will be reflected in the case load of Lewisham A&E - more manual work leading to accidents, for example. It might also be reflected in number of responses to the APOH consultation, fewer people from an area of higher deprivation will be in a position to respond.

The loss of a consultant led maternity unit will have a direct negative impact of addressing this issue. Deprivation is a factor in increased mortality and morbidity rates. The high number of teenage pregnancies and late presentations in Lewisham

and the diverse population are factors affecting use of these services. Over 50% of expectant mothers in Lewisham were themselves born outside of England, which suggests they do not have the natural extended family locally to support them in child birth. The caesarean section rate in Lewisham in 2006/07 was 31% against a national average of 23.5%. The Lewisham figure is considerably higher than in the southern part of the APOH area, it would suggest that any centralisation of obstetric and neonatal services should be near the area of greater need rather than moving it away.

The loss of maternity services in Lewisham will result in a denial of choice. This will most affect those who are less articulate and more vulnerable who will not necessarily question the decisions taken on their behalf by the medical practitioners. For those in living in poorer housing conditions the option for home births will not be seen as viable. Many of the current policy drivers in healthcare are about patient choice this will not exist for many Lewisham residents.

The options outlined in APOH place a greater reliance on travel for patients and their carers/visitors, this will have the greatest adverse impact on Lewisham residents with a lower car ownership and greater high levels of deprivation.

The demographics of Lewisham, a high transient population, a more diverse population, the sudden increase in population expected and the higher deprivation makes us apprehensive that the take up of community services and primary care will be sufficient to deliver conditions required for APOH. If the changes go ahead in the hospital provision and the improvement in community services are not accessed by residents, the safe being of these more vulnerable Lewisham residents will be jeopardised.

APOH will lead to an increase in the carbon foot print and will have a detrimental environmental impact.

Each PCT and government at every level claim to have regard towards the environment. They should have full and proper regard to the environmental impact of all their activities, policies and planning. There should be an Environmental Impact Study included as part of the public consultation. The premise of APOH is that fewer sites, separating planned and emergency care on to different sites and larger more specialist teams will provide improved health care and address the budget constraints facing the Trusts with PFI debts. The corollary of this is that patients will have to travel further for care. The ambulance service will be used more to transfer patients around South East London and carers and visitors will need to travel around the area. Public transport in South East London is deficient, it lacks an underground system and most links run north south and not east west making some journeys very difficult and the reliance on the car greater.

There will be greater pressure on the already congested road network. The congestion can often result in gridlock, whether caused by an incident such as the closure of the Blackwall Tunnel, a road traffic accident or road works in a strategic position or Christmas shoppers making the A21 impassable through Bromley in December. This problem will be considered normal urban living by many residents, they in return would expect health services to be closer geographically and able to meet metropolitan standards. The travelling time between Lewisham Hospital and the Princess Royal Hospital will be unacceptable and may put some patients at risk.

The APOH states that there will be more investment in the Ambulance service to take account of the reduced number of A&E departments. If ambulances are travelling further crews will be occupied longer, in addition to this there will be a greater need for transport and would appear to create another capacity concern. It is not clear to the lay person whether APOH envisages transfers between hospitals for patients with multiple health problems; this will place further strain on the ambulance service and on the road network.

As local councillors we are concerned about the interface between a Council's Social Services department and with a hospital. Currently a close working relationship exists with Lewisham Council social workers based in University Hospital Lewisham doing joint assessments for discharge, ensuring the correct support exists in the community or at home for a patient. It is not clear whether the Council will need social workers travelling around four hospitals in the sub-region. Or whether social workers based several miles away in another borough will visits homes for assessments. Each local authority has different support available in the community, different criteria for assessments and devotes a variable amount of resources to these services. We would object to one policy across the area and think this would be impossible to achieve. There is a danger of vulnerable people being discharged into an environment unknown to the hospital and without appropriate support.

In conclusion, may we add our concern about the future of The Children's Hospital, Lewisham. It is our understanding that when the future of the famous Sydenham Children's Hospital was previously threatened it was agreed to transfer the services to Lewisham Hospital. Since then a centre of excellence has been developed for General Paediatric Surgery and Rhesus Disease, the hospital treats children from as far afield as Kent, Surrey and Sussex. The Children's Hospital is not just the buildings, it is the team of staff that have worked to create the national reputation for excellence to move or break up this team will lead to a deterioration of care. We would deplore any moves to destroy this.

Related Links:

Lewisham Lib Dem councillors.

A Picture of Health consultation.