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NHS: London

Volume 748: debated on Wednesday 30 October 2013


My Lords, with the leave of the House, I shall now repeat a Statement made by my right honourable friend the Secretary of State for Health in the other place earlier today on changes to health services in London.

“With permission, Mr Speaker, I would like to make a Statement on the Shaping a Healthier Future programme, a locally led review of NHS services across north-west London.

The NHS is one of the greatest institutions in the world. Ensuring that it is sustainable and that it serves the best interests of patients sometimes means taking tough decisions. The population of north-west London is growing, and will reach approximately 2.15 million by 2018. Around 300,000 people have a long-term condition.

However, there is great variation in the quality of acute care. In 2011 there was a 10% higher mortality rate at weekends for emergency admissions, and the number of hospital readmissions differs considerably across the area. The Independent Reconfiguration Panel expressed concerns that the status quo in north-west London was neither sustainable nor desirable, and might not even be stable.

In order to address these challenges, the NHS in London started the Shaping a Healthier Future programme in 2009. It proposed significant changes to services, including centralising A&E services at five hospitals rather than nine; 24/7 urgent care centres at all nine hospitals; 24/7 consultant cover in all obstetric wards; a brand new trauma hospital at St Mary’s Paddington; brand new custom-built local hospitals at Ealing and Charing Cross; seven-day access to GP surgeries throughout north-west London; over 800 additional posts created to improve out-of-hospital care, including a named accountable clinician for all vulnerable and elderly patients, with fully integrated provision by the health and social care systems; and increased investment in mental health and psychiatric liaison services.

These changes represent the most ambitious plans to transform care put forward by any NHS local area to date. They are forward thinking and address many of the most pressing issues facing the NHS, including seven-day working, improved hospital safety, and proactive out-of-hospital and GP services. The improvements in emergency care alone should save around 130 lives per annum and the transformation in out-of-hospital care should save many more—giving north-west London probably the best out-of-hospital care anywhere in the country.

The plans are supported by all eight clinical commissioning groups, the medical directors of all nine local NHS trusts, and all local councils except for Ealing. It was as a result of a referral to me by Ealing Council on 19 March 2013 that I asked the Independent Reconfiguration Panel to conduct a full review. The panel submitted its comprehensive report to me on 13 September 2013, which I have considered in detail alongside the referral from Ealing. I am today placing a copy of the panel’s report in the Library, alongside the strong letters of support for the changes I received from all local CCGs and medical directors.

The panel says that Shaping a Healthier Future provides,

“the way forward for the future and that the proposals for change will enable the provision of safe, sustainable and accessible services”.

Today I have accepted the panel’s advice in full, which will be published on the panel’s website.

The panel also says that while the changes to A&E at Central Middlesex and Hammersmith hospitals should be implemented as soon as practicable, further work is required before a final decision is made about the range of services to be provided from the Ealing and Charing Cross hospital sites.

Because the process to date has already taken four years, causing understandable local concern, I have today decided it is time to end the uncertainty. So while I accept the need for further work as the IRP suggests, I have decided that the outcome should be that Ealing and Charing Cross hospitals should continue to offer an A&E service, even if it is a different shape or size to that currently offered. Any changes implemented as part of Shaping a Healthier Future should be implemented by local commissioners following proper public engagement and in line with the emerging principles of the Keogh review of Accident and Emergency services.

I have written today to the chair and vice-chair of the Health and Adult Social Services Standing Scrutiny Panel of the London Borough of Ealing Council, the chair of the IRP—Lord Bernard Ribeiro—the chief executive of NHS England and local MPs, informing them of my decision. These much needed changes will put patients at the centre of their local NHS, with more accessible, 24/7 front-line care at home, at GP surgeries, in hospitals and in the community. More money will be spent on front-line care which focuses on the patient. Less will be wasted on duplication and underperforming services.

Let me be clear that, in the joint words of the medical directors at hospitals affected, there is a,

“very high level of clinical support for this programme across NW London”.

Local services will be designed by clinicians and local residents and be based on the specific needs of the population. None of these changes will take place until NHS England is convinced that the necessary increases in capacity in north-west London’s hospitals and primary and community services have taken place.

I want to put on the record my thanks to the IRP for its thorough advice. As the medical directors of all the local hospitals concerned said in their letter to me, these changes will,

“save many lives each year and significantly improve patients’ care and experience of the NHS”.

When local doctors tell me that is the prize, then I will not duck a difficult decision.

I commend this Statement to the House”.

My Lords, that concludes the Statement.

My Lords, I am grateful to the noble Earl, Lord Howe, for repeating the Statement. I refer noble Lords to my interests, particularly as chair of a foundation trust.

Decisions on hospital reconfiguration should always be made on the basis of the best clinical evidence available. The noble Earl’s announcement today means the closure of a number of accident and emergency departments in London, with the centralisation of A&E services at five, rather than nine, hospitals. That is to happen at the same time as accident and emergency departments are under heavy pressure up and down the country, not least in London. Taking all major A&E units together, London as a whole has missed the Government’s A&E target in 48 out of the past 52 weeks. Is the noble Earl convinced that the system will be able to cope with the reduced number of A&E departments in London?

I note that the chief executives of the three major health regulators have been summoned to meet the Prime Minister to discuss the pressure that services are likely to come under this winter. These meetings are complementary to the weekly meetings that the Secretary of State has with these eminent people. Apparently these discussions are dominated by winter performance planning, particularly relating to accident and emergency departments. What measures are being taken to increase capacity in the community, to enable the flow of patients and their discharge at the right time?

What is being done about the accessibility of general practitioners? We heard much from the Prime Minister about a move to seven-day-a-week access, which the noble Earl will know has provoked a lot of opposition from primary care interests, citing cost at a time when the NHS is cash strapped and when there is a shortage of general practitioners. Does that mean the inevitable merger of smaller GP practices? Can the noble Earl spell out the Government’s intentions? In the Statement, we are told that there is to be seven-day access to GP surgeries throughout north-west London. Can the noble Earl confirm that that means that all surgeries will be open from 8 am to 8 pm, seven days a week? If that is not the case, what happens to patients in practices which are not prepared to open seven days a week?

I now turn to the noble Earl’s announcement about Charing Cross and Ealing hospitals. Very simply: is this a permanent reprieve? The report of the Independent Reconfiguration Panel says that the future of the proposed local hospitals at Ealing and Charing Cross, and the final decision about what might best be provided from each location must be the subject of a specific programme of work which should address the needs for in-patient services for the vulnerable and frail elderly, and that its outcome would determine whether there is a need for further consultation. In his Statement, the noble Earl has said that, whatever the outcome of that further work, Ministers have decided that Ealing and Charing Cross hospitals should continue to offer an A&E service, even if it is a “different shape or size” to that currently offered. Can the noble Earl spell out what, exactly is meant by that? Can he guarantee that both Charing Cross and Ealing hospitals will continue to run full, 24-hour A&E services in the long term?

The Statement is about hospitals in London. I was surprised that the noble Earl made no mention of Lewisham Hospital. The victory won by the people of Lewisham in the Court of Appeal yesterday will give hope to patients everywhere. Back in the summer, the Opposition explicitly warned the Secretary of State to accept the first court ruling. Instead, he ploughed on with a hopeless case, wasting taxpayers’ money in a cavalier fashion. Will the noble Earl confirm that there will be no further appeal to the Supreme Court? Will he give the people of Lewisham and the staff who work in Lewisham Hospital a commitment that their accident and emergency and maternity units will be protected in the long term? Given that the Lewisham clinical commissioning group opposed those changes, what does it say about the assurances that he gave during the passage of the Health and Social Care Act 2012 that the whole purpose of those misguided changes was actually to let local clinicians decide? What happened to that in Lewisham?

The noble Earl tabled an amendment to the Care Bill only a few days ago, which he described as making a small change, so he will of course know that the Government have sought, very rapidly and very quietly, to change the law so that what happened in Lewisham cannot happen again. My interpretation of that amendment is that in the future there is a risk of services being shut down without the agreement of local people, without extensive consultation and without agreement from local commissioners. We, on this side of the House, support reconfiguration of health services when supported by the clinical evidence, but it must be on the basis of a requirement to go through a properly defined and structured reconfiguration process with extensive consultation with the local community.

From all we have learnt, we know that successful reconfigurations need to take the form of open and honest leadership, a patient process of engagement and consultation and proper consideration of the wider impact. The changes that the Government seek to make in legislation will ensure that that does not happen in the future. I hope that the noble Earl will be able to say that, in the light of yesterday’s ruling, the Government are giving second thoughts to their intentions in this regard.

My Lords, I am grateful to the noble Lord, Lord Hunt of Kings Heath, for his questions. I preface my answers by saying that this is the first significant set of local reform proposals under the Government’s NHS reforms and it is a set of proposals that has been led clinically by the CCGs. There is an unprecedented level of clinical support for the changes that I outlined. The chairs of all the local CCGs wrote to the Secretary of State personally expressing absolute support; the medical directors of all the local hospitals affected wrote to him expressing absolute support; and the Independent Reconfiguration Panel report is crystal clear that the principles of this scheme are right and will benefit patients.

The noble Lord asked me about A&E services, in particular, at a time when we know that A&E departments are under pressure—a fact which I do, of course, readily acknowledge. The key to these recommendations is twofold. First, the way investment will be deployed will mean that we shall have centres of excellence in emergency care which will copy, in some respects, the way that stroke and trauma care has been centralised across London. This was controversial at the time but is now acclaimed by clinicians and, I think, politicians alike as proving to save hundreds of lives every year. There will be more critical care consultants on duty 24/7; more obstetric consultants on duty 24/7 on labour wards; consultants in other specialities, such as paediatrics, on duty between 12 and 16 hours a day, seven days a week; more trained and experienced emergency doctors on site 24/7 in A&E departments; and more investment in mental health, so that psychiatric liaison services can better co-ordinate care for vulnerable mentally ill people. In general, we will have all nine of the hospitals concerned across north-west London with urgent care centres open 24/7.

That is one half of the equation; the other half is investment in the community. I mentioned that there will be access to GP surgeries seven days a week across north-west London. That is not to specify which surgeries —the key is access to GP services. It will be for the local commissioners and NHS England to work out which surgeries they should be. Eight hundred additional posts will be created to improve out-of-hospital care and some £190 million will be spent recurrently every year on GP and other local services by 2017-18. Therefore the preventive aspect of these proposals should mean that fewer people land up in A&E in the first place.

The noble Lord asked me about the proposals for Ealing and Charing Cross. The IRP’s advice is clear that the current problems and future challenges faced by the NHS in north-west London require large-scale change in the way that services are designed and delivered. I concur with that entirely. However, it also says that while the changes to A&E at Central Middlesex and Hammersmith Hospitals should be implemented as soon as practicable, further work is required before a final decision is made about the range of services to be provided from the Ealing and Charing Cross Hospital sites. As the process to date has already taken four years, as I mentioned, my right honourable friend has decided that it is time to end the uncertainty. Therefore, while he accepts the need for further work, as the IRP suggests, he has decided that the outcome should be that Ealing and Charing Cross Hospitals should continue to offer an A&E service, even if in the end that is of a different shape or size from that currently offered. What does that mean?

In the first instance, we are clear that a 24/7 urgent care service should be run from both those sites, involving senior consultant cover and the ability to admit patients 24/7. Any changes implemented as part of the Shaping a Healthier Future proposals should be done by local commissioners following proper public engagement and in line with the emerging principles of the Keogh review, as I mentioned. However, none of the changes to these critical services will take place until NHS England is assured that all the necessary increases in capacity in north-west London’s hospitals and primary and community services have been satisfactorily developed.

The noble Lord asked me about Lewisham. I will not disguise the Government’s disappointment at the result of the court judgment yesterday. However, we respect that judgment. Our priority now is to end the uncertainty for patients in south London. It is time for the new Lewisham and Greenwich NHS Trust to move on and work with its commissioners and the community to develop a local solution that is clinically and financially sustainable. The proposals that we came forward with earlier in the year cannot be proceeded with in their entirety. In our view that is a pity, because we now have a local health economy with an annual financial shortfall, which has to be addressed in some way. In so far as we can assist local commissioners to find a way through that problem, we will be happy to do so. However, it is largely up for local determination.

As regards the appeal, we felt that that was the right and responsible thing to do. This is the first time that the trust special administration provisions have been used and it was important that the law should be tested to be absolutely clear what it meant. We make no apology for the fact that our interpretation of the law as Ministers was different from that of the judge. However, as I said, the judge has made his ruling, and we need to respect it.

I hope that I have answered most of the noble Lord’s queries. However, he ended his remarks by observing that, as he perceives it, the Government have created a situation where service configuration can take place in the future without local clinical support or consultation. I would just like to assure him that that is not so. Indeed, the importance of having local clinical support could not be stronger. We see it here in the example of north-west London, and even in the rare case where trust special administration is required, the consultation involved is clearly set out in legislation. Local people will not be left out of the dialogue. I hope that that is of some reassurance to the noble Lord.

My Lords, may I say how glad I am to hear that the proposals have support from all the clinicians and the CCGs? The noble Lord will know that I was chairman at St Mary’s Hospital when the Imperial College Healthcare NHS Trust was formed —and it was formed on the basis of full support from clinicians and the local community. The local community is not always at one with change, so I shall ask the noble Lord a couple of questions. First, this is not a short programme. These proposals will not take five minutes to implement. Most of the changes in the health service over recent years have taken an enormous amount of time, and it would be fair to say that the Imperial Trust, which includes Charing Cross, has probably only just completed its previous reorganisation, and now it is being reorganised again. The first question is: what is the proposed timescale?

Secondly, the noble Lord mentioned consultation, and may I say that it is absolutely vital that the local community be brought along with this? Otherwise, it will take even longer. Thirdly, there is an expectation that there will be a lot of new consultant and other medical posts. I am aware that A&E is not flush with clinicians taking up the specialty, so may I ask what encouragement is being given, by the colleges in particular, to ensure that there will be enough staff available to deal with the new services? Finally, may I say how glad I am that St Mary’s has figured again in trauma services?

My noble friend, with her experience, asks some very pertinent questions. On the question of timescale, we believe that it will take between three and five years for the proposals to be actioned to their fullest extent. It will be necessary to take that kind of time. Some elements can happen relatively quickly, but my noble friend is absolutely right that there are important workforce issues to be taken into account. Indeed, one of the IRP recommendations was that the NHS should review its workforce programme and ensure that it has the means in place to deliver what is required. I am sure that in working through the proposals, local commissioners, as well as NHS England, will need to satisfy themselves on that point—not least with regard to the new posts to be created in the community, but also in terms of accident and emergency consultants in the A&E departments of the relevant trusts. On local communities, again I agree with my noble friend. As the Shaping a Healthier Future proposals are developed by the clinical commissioners, it will be vital that any further proposals are consulted on locally, and that there is real buy-in from patient groups and the public generally.

I declare an interest as a member of Imperial College London and a practitioner who has been a consultant in north London for a long time. It is right that the financial shortfall means that there has to be considerable reconfiguration. In this case that is a move in the right direction. However, it raises a number of questions to which I would be very grateful if the Minister would respond. One is that if you close casualty you affect the training of surgical trainees. Do the Government have a view on that issue?

The Minister also referred to obstetrics in west London. As he will almost certainly know, the neonatal paediatrics department at one of the best obstetric hospitals in the country—Queen Charlotte’s, based at Hammersmith Hospital—has always been somewhat threatened. Is that secure, given that one of the issues in north-west London is undoubtedly that of duplication in many hospitals, which is expensive? Does the Minister feel that this is the only reconfiguration that will be required, given the amount of duplication that there is?

To answer the last point, it is clear from the IRP report that its authors believe that this is a comprehensive set of proposals which will stand the test of time in north-west London. It is a very thorough set of proposals which takes into account every aspect of healthcare provision. On maternity and paediatrics, I can tell the noble Lord that under these proposals there will be more obstetric consultants on duty 24/7 in labour wards. As he will know better than anyone, that, of course, is designed to reduce the number of complications during birth and to ensure one-to-one midwifery care for women during labour. Consultants in other specialties such as paediatrics will be on duty, as I mentioned, for 12 to 16 hours a day, seven days a week, providing much better cover than at present.

It was very striking in the IRP report that the first point made by the noble Lord, Lord Winston, did not elude the panel. The panel concluded that the pragmatic and explicit approach used by the NHS reflected the clarity of the aim to improve quality outcomes by implementing life-saving standards through the establishment of major hospitals. The report referred to the economic realities of the NHS and the urgency of making progress in the light of known risks to the sustainability of emergency services such as the abilities of staff, A&E and emergency surgery rotas, and the desire to minimise the negative impact on access of concentrating services. That was shorthand—as the noble Lord will see if he reads the rest of the report—for saying that the desirability of concentrating expertise in centres of excellence is a clear imperative for the quality of care that patients receive. As regards surgical experience, I think that if my noble friend Lord Ribeiro were here, he would confirm that that is absolutely the direction of travel, but that we must ensure that surgical expertise is built on a sufficient number of hours and cases for the quality of care to be maintained. That is exactly what underlies this whole set of proposals.

My Lords, since the relevant professional bodies, not least the British Medical Association, have decided that they wish to support a move towards the provision of all acute and relevant services in the NHS for a full seven-day period, it is inevitable that there will be major reconfiguration of services not just in north-west London but in many other parts of the country. This will involve the concentration of specialist services in fewer hospitals and could even result in the closure of some smaller hospitals. However, that is not immediately relevant. The point I will make is that it is good to know that the clinical commissioning groups and the local hospital trusts have all supported this proposed reconfiguration.

However, I must ask the Minister a couple of questions. First, is he satisfied that the five A&E departments into which all accident and emergency services are to be concentrated, with four others closing, have the capacity to provide facilities for all the relevant staff and to deal with the increased number of patients who will go through those five hospitals? That is point number one, which is crucial.

Secondly, is the Minister satisfied that this concentration of services, with the new 800 posts in the community to which he referred, can be carried out within the existing financial constraints? Have these changes been costed? As the Minister knows, under the so-called Nicholson challenge, the NHS is required to make substantial savings across the country over the next year or so, and it is crucial that he can reassure the House that the necessary money will be available to provide this reconfiguration, which is clearly in the best interests of patients and their communities.

My Lords, the noble Lord raises the important question of capacity. The key point is that none of these changes will be implemented until such time as commissioners and the relevant providers are satisfied that the necessary capacity exists. That is a key point. Secondly, on the costing and the financial aspects of the proposals, the way in which we will be able to spend more money on front-line care and better-quality facilities is by spending less on duplicated facilities, underperforming services, and badly designed and out-of-date buildings, which cost a lot to maintain. Therefore, as part of this package, there will be new custom-built hospitals at Ealing and Charing Cross, costing about £80 million each, designed to deliver the specific services needed in those respective communities. That will be part of the way in which the money released will be invested for the betterment of patients in the area over future years.

My Lords, the most important part of this Statement is the part stating that none of these changes will come into effect until NHS England is convinced that the necessary primary and community services are in place. How will that be determined by NHS England? Secondly, who will be responsible for the integrated commissioning of community and primary services to bring about the necessary preventive services on which this reconfiguration is based?

Largely, the judgment by NHS England will be made by local area teams—but not in isolation. It has to be a collaborative exercise, which is my overall answer to my noble friend’s second question. The successful integration of services must depend on close collaboration between the different constituent parts of the NHS but also with adult social care and local authorities. It is striking that already we are seeing this happening in north-west London, as we are in many other parts of the country. For the system to work as we want it to, all the constituent parts need to be effective and efficient. The integration of services, which is one example of how the NHS can become more productive in the future, as well as more clinically effective for patients, is an essential way of ensuring that we have a sustainable NHS in the future.

Will the noble Earl confirm, first, that there will be no further appeal in respect of Lewisham hospital after the decisions of two courts; and, secondly, that there will be no attempt to change the law in respect of Lewisham hospital? What lessons have been learnt by the noble Earl and his ministerial team that they can apply to what is going on in north-west London? We are all aware that the Minister has never visited Lewisham hospital; the last ministerial visit was in May 2010. Will he tell the House—if not from the Dispatch Box, then by writing and placing a copy in the Library—when Ministers last visited the hospitals in north-west London that have been mentioned?

I can certainly find out the answer to that last question. As regards the appeal, we have only just received the judgment, as the noble Lord will know. But that is only the outline judgment. We have not received the full text. It is important that we read that and inwardly digest it before we finally decide on the way forward. The lessons of Lewisham are very clear. I confirm that we shall not be legislating around Lewisham and the recent provisions in the Care Bill were not retrospective, as the noble Lord is aware. I have not personally visited Lewisham, which is clearly an omission that I should at some point rectify, but it is important for me to put on the record that the concerns expressed by the people of Lewisham are, and have always been, entirely understandable. Ministers greatly respect the wish of local residents to see their hospital thriving, as it always has in the past. Nevertheless, as I said earlier, Lewisham and Greenwich now have a challenge. There is a financial issue that needs to be addressed and I hope that commissioners and providers, acting together, can do that successfully over the months ahead.

My Lords, can the Minister say whether, if A&E departments are shut, hospitals will be downgraded? Will the resources of the ambulance service be increased to transport ill patients around, as the ones with A&E departments may not have enough capacity to treat them?

I do not think that it is appropriate to talk about downgrading in this case. However, it is appropriate to talk about changing the way in which services are delivered to the local population. In the case of two hospitals, we are seeing fully fledged A&E departments becoming 24/7 urgent care centres. That means that the most serious A&E cases, such as trauma and cardiovascular emergencies, will be taken to centres of excellence where patients will have a much higher chance of survival. That is a pattern that we are seeing throughout the NHS and one that has been proved to be successful and in the interests of patients. On ambulances services, we are already seeing in London, for example with stroke care, ambulances taking patients to centres of excellence for stroke care. Eight of these centres now exist compared to 32 some years ago. That means longer journeys in an ambulance but also much higher survival rates for the patients. I do not think that we should look on the kind of reconfiguration that I have described in a negative way. On the contrary, the whole thrust of these proposals is to improve the quality of care for patients.

The noble Earl said that, as part of this reconfiguration, there will an increase in the services available in the community. Can he say whether this will be done in co-operation with the royal colleges and the British Medical Association rather than being imposed from above? The latter solution is unlikely to work.

The noble Lord is absolutely right. These solutions should not be imposed from above. Indeed, the Shaping a Healthier Future proposals were designed by local clinicians in consultation with their patients. It was not a prescription dreamt up in Whitehall. We are very clear that the local NHS should continue to feel local ownership of these ideas as it takes them forward. I have no doubt that, if it feels it necessary, it will turn to the royal colleges for particular kinds of advice. It is free to do that as it wishes.

Is the noble Earl aware that on this side of the House he is very highly regarded as a model of clarity? However, in the second part of his answer to the noble Lord, Lord Hunt, today, he was somewhat equivocal in relation to the future of Lewisham Hospital. I hope that he will accept an invitation to visit Lewisham Hospital. I declare an interest as somebody who lives in that area and has opposed the closure. Does he also realise that such is the strength of feeling in Lewisham, he had better have read the whole judgment carefully and cleared all his lines before he goes there? The threatened closure created such community anger as I have never seen before and he would be most unwelcome unless he were able to give a clear and unequivocal response about its future.

My Lords, I certainly understand the noble Lord’s strength of feeling on this. It is certainly my intention to read the judgment when we receive it in full. Nothing is closing in Lewisham. The service remains as it has been. There is nothing that Ministers intend to do to change that situation. However, as I mentioned earlier, there is an issue to be addressed in Lewisham and indeed in Greenwich. It is a pressing financial issue that commissioners as well as the hospitals themselves have to face. I have no doubt that a visit to Lewisham would benefit me enormously and I shall await an invitation to that effect.