Why Clinical Senate is wrong to say centralisation of specialist hospital services can solve Care Closer to Home capacity problems

A Clinical Senate rep at the 22nd March Joint Health Scrutiny Committee meeting tried to dodge a question from the Chair, Cllr Smaje, about when the Clinical Senate would say whether the system as a whole would be able to cope with the proposed hospital cuts.

He said:

“Integration of services needs further work. When we are invited to come back we will be looking to see if that’s happening. Centralisation of specialist services is one way of solving this problem.”

This  contentious claim is an attempt to sidestep the problem raised by Cllr Smaje, that:

  • the proposed “centralisation” of acute and emergency services” is in fact a proposed cut,
  • the ability to make that cut safely depends on Care Closer to Home having the capacity to provide alternative services to the acute and emergency services that are to be cut
  • part of the capacity question is whether or not the Clinical Commissioning Groups have a workable plan for integrating all the various services required in the Care Closer to Home scheme

Regardless, Prof Welsh, one of the Clinical Senate reps, told the 22nd March meeting that the senate fully supported the strategic direction in the proposals, and

“..the centralisation of some services to deliver care to patients affected by serious conditions is entirely appropriate…There is strong clinical evidence that this delivers much better outcomes for patients, particularly those affected by stroke, by heart attack and by major trauma.”

Centralising acute and emergency services doesn’t always improve things for patients & there are risks with cutting existing A&Es

But the British Medical Association says that centralising acute and emergency services doesn’t always improve things for patients and there are risks associated with cutting existing A&E provision. A BMA article accepts that in London, some patients who would’ve been expected to die of their injuries have survived as a result of the introduction of four major trauma centres with 24/7 consultant presence. But in London, most patients are within a short travel time from home to major trauma centre.

The BMA are concerned about increased deaths that have been linked to the closure of Newark A&E, which led to longer patient journeys to A&E.

The data on increased patient deaths related to the closure of Newark A&E comes from a Freedom of Information request made by the Say Yes to Newark Hospital campaign group – info here in the minutes of the 2013 Say Yes to Newark Hospital Annual General Meeting.

The campaigners’ FoI request asked for specific data on the ‘30 day death rates’. That data shows that since the closure of Newark A&E, mortality rates have increased for patients from the Newark NG23/NG24 areas since 2008 – whilst it has fallen for other patients from other areas visiting the same hospitals. Based on these figures, the Mail on Sunday published a front page story on Newark and mortality rates, claiming death rates for emergency patients from Newark had shot up 37% since the closure of that A & E.

The Say Yes to Newark Hospital AGM Minutes say that following this, there was a House of Commons debate and later Daniel Poulter, the junior Health Minister, visited Newark Hospital and said,

‘We have to provide more care away from the big hospitals. It is much better for people to be looked after in a hospital like Newark than be rushed off to a big hospital elsewhere.’

Calderdale 38 Degrees NHS Campaign Group are calling for the Clinical COmmissioning Groups to do a risk assessment of the likely increase in patient deaths associated with the proposed closure of Huddersfield A&E.

There is also a lack of evidence for the frequently made claim that A&Es must merge since small hospitals don’t let consultants maintain clinical skills. In 2007, when Rochdale Council were faced with their version of the Right Care Right Time Right Place scheme, a report by Sally Ruane of the Health Policy Research Unit at DeMontfort University found no reliable evidence of a correlation between the population size of a hospital, patient outcomes and by implication, the consultants’ clinical skills:

“The matter is an important one since documents produced by local health organisations for the purpose of consulting the public formally may contain inaccurate and potentially misleading assertions.”

This lack of evidence about an optimal hospital size is borne out by Sir Derek Wanless in his 2007 Report, Our Future Health Secured?

And a study of the relationship between case mix and throughput, and health outcomes for stenting heart patients found no difference between high volume and low volume hospitals. (Heart 2006;92:1667–1672. doi: 10.1136/hrt.2005.086736)

A recent big 2014 Californian study showed the negative impact of A&E closures not only on the places where they had closed, but also on the neighbouring A&Es. This study – California Emergency Department Closures Are Associated With Increased Inpatient Mortality At Nearby Hospitals, by Charles Liu, Tanja Srebotnjak and Renee Y. Hsia (doi: 10.1377/hlthaff.2013.1203 Health Aff August 2014 vol. 33 no. 8 1323-1329) found that when a nearby A&E closes, the inpatient death rate in hospitals that still have an A&E goes up. Patients who still had a local A&E department had 5 percent higher odds of inpatient mortality than admissions not occurring near a closure. This was because of overcrowding from a neighbouring area where the A&E had closed.

Two academic studies – reported in the Journal of Emergency Medicine and the Journal of Trauma and Acute Care Surgery – have also found that that increased distance to A&E is associated with increased risk of death. That will definitely not be good for people in Huddersfield.

Hospital “reconfigurations” to create centralised specialist care are about money not clinical evidence

It is not the case that clinical evidence supports the reconfiguration of hospitals to create centralised specialist hospitals. Academic health policy assessments of NHS reconfigurations that involve the centralisation of services from two or more hospitals, and the sale or downgrading of the other sites, have found no evidence that the reconfigurations are underpinned by clinical evidence.

In a BMJ article about planning the “new” NHS for PFI hospitals, Prof Pollock and others pointed out that planning was based on financial, not clinical, needs. The pattern has been that total capacity has been decided on financial grounds and then clinical decisions have been confined within the financial limits.

The trend to NHS hospital service specialisation was accelerated by Tony Blair’s claim in a widely reported speech in 2007 that this would save hundreds of lives – a claim based on evidence that health policy academics assessed as selective and often used misleadingly.

Tony Blair’s speech was based on the Future Hospital Commission report by a think tank called the Institute for Public Policy Research (IPPR), which has a record of close collaboration with organisations that stand to benefit from NHS privatisation. The report was sponsored in part by a commercial organisation, Prime PLC, with a vested interest in hospital reconfiguration.

Dodgy dossier

Keep Our NHS Public campaigners judged it to be a “dodgy dossier”.

The political context for the IPPR’s report was a need to overcome opposition to the closure of local services, by claiming that clinical evidence supported the push towards reconfiguring hospitals into centralised specialist hospitals.

The New Labour government’s drive for centralised specialist hospitals was precipitated by an NHS budgetary crisis brought about by the costs of:

  • introducing a competitive market in the NHS and payment by results
  • privatisation through PFI, Independent Sector Treatment Centres (Darzi Clinics) and other public private partnerships.

Hospital mergers and so-called rationalisations – including selling or mothballing assets – were kicked off by the 1990 NHS and Community Care Act that required Trusts to balance their budgets

But even the financial assumptions behind the pressure for concentrating hospital services through rationalisation and trust mergers were shaky, as a 1999 study by John Posnett, published in the British Medical Journal, showed (BMJ. 1999 Oct 16; 319(7216): 1063–1065. PMCID: PMC1116851) John Posnett.  ‘The hospital of the future. Is bigger better? Concentration in the provision of secondary care’ concludes:

“The logic is inescapable: larger units reduce average costs through the operation of economies of scale and larger units improve patient outcomes by increasing average volumes of activity by clinicians. Unfortunately, this logic is not supported by the evidence…Evidence from research does not support any general presumption that larger hospitals benefit from economies of scale or that service concentration leads to improved outcomes for patients. Service planners would do well to give more prominence to the really be necessary. It says this can lead to more suboptimal care and overtreatment, and also push up costs.”

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