After more than two years of secretive developments, on Weds 5th March Lincolnshire Sustainability and Transformation Partnership finally started public “engagement” on proposals for huge Lincolnshire-wide cuts and changes to the county’s NHS services.
This blog post is about the hospital cuts and centralisation proposals, which are key to this reheated Lincolnshire Sustainability and Transformation Plan.
You can find an overview of the engagement process and Sustainability and Transformation Partnership proposals here. An outline of plans to move Grantham Hospital medical services into a Neighbourhood Team is here. The failings of Lincolnshire Health and Overview Scrutiny Committee are summarised here. [link coming soon]
Lincolnshire Sustainability and Transformation Plan was first announced in 2016 and rejected in a futile, grandstanding vote by Lincolnshire County Council. This had no effect on Lincolnshire Sustainability and Tranformation Partnership under John Turner’s leadership, which continued to develop the Plan by stealth. And the Lincolnshire Health Scrutiny Committee looked the other way.
By drastically increasing distances people would have to travel for both acute and emergency AND planned healthcare and surgery, these hospital cuts and centralisation proposals would worsen health inequalities and increase patient deaths.
Public transport is thin on the ground. Last time members of the public raised the issue of transport, local NHS organisations brushed it off as not their problem. It very much is their problem. They have a duty to carry out an equalities impact assessment AND a risk assessment. Transport-related lack of access to hospital services is very relevant to both.
And the problem is not just lack of transport, it’s also about bad weather and road works. When you take them into account, just how safe are these hospital cuts and centralisation proposals? Not!!! They create an extremely dangerous situation.
Summary of proposed hospital cuts and centralisations
Centralisation of A&E services for serious or life threatening accident or illness at Lincoln and Pilgrim Hospitals.
This would mean the permanent closure of Grantham A&E. This would cement the need for people to travel much further to A&E elsewhere. This has been unacceptable during the so-called “temporary” overnight closure, pending engagement and consultation, and it would continue to be so.
Lincolnshire Sustainability and Transformation partnership have to look fairly and squarely at the potential for patient deaths on the way to distant A&E departments and tell us how they square that with their proposals.
Greater distances to A&E are associated with increased patient deaths.
They are also associated with worsening health inequalities. Relocating services has a disproportionate effect on poorer and more vulnerable people. The Royal College of Emergency Medicine’s statement on Emergency Department closure and reconfiguration includes the following information:
- Relocating services has a disproportionate effect on the very young, the very old, patients with mental health issues and those with chronic illness or reduced mobility.
- Relocation also has a greater impact on poorer socioeconomic groups through difficulties with transport.
- The likelihood of transportation difficulties will be higher in rural areas.
Lincolnshire probably has the poorest roads in the country and most are single carriageway. Distances are great in this large county with dispersed rural populations.
The Lincs STP video says the Urgent Treatment Centre will take patients brought in by ambulance – but children are not usually brought into Grantham A&E by ambulance so they won’t be brought into the Urgent Treatment Centre.
A&E closure is associated with increased mortality in neighbouring hospitals with A&Es
A big Californian meta study of impacts on inpatient mortality in hospitals retaining their A&Es when a neighbouring A&E closes, found the effect was to increase mortality in the hospitals that retained their A&Es. (The study is “California a Emergency Department Closures Are Associated With Increased Inpatient Mortality At Nearby Hospitals”, Charles Lui AB, Tanja Srebotnjak PhD, and Renee Y. Hsai MD, (2014). The full abstract with appendixes and bibliography is available to view here )
Urgent Treatment Centres
The proposal is to set up Urgent Treatment Centres at Lincoln, Pilgrim, Grantham, Louth, Skegness and Stamford Hospitals and explore options for Spalding and Gainsborough.
Urgent Treatment Centres are supposed to reduce attendance at A&E. Currently both Lincoln and Pilgrim A&E departments are inadequate to the task.
Urgent Treatment Centres would only deal with minor illness and injury in adults and children of any age, including wound closure, removal of superficial foreign bodies and the management of minor head and eye injuries.
NHS England says Urgent Treatment Centres are GP-led and also include a multidisciplinary team. The Acute Services Review online questionnaire says that hospital clinicians would provide specialist advice at Grantham Urgent Treatment Centre.
A full resuscitation trolley and drugs should be immediately available and at least one member of staff trained in adult and paediatric resuscitation should be present in the urgent treatment centre at all times.
If critically ill and injured adults and children arrived at the urgent treatment centre unexpectedly, they would be taken by ambulance to the “correct facility.” For Grantham patients, this means a 25 mile journey to Lincoln A&E and 35 miles to Pilgrim A&E.
NHS 111 is key means of access
Patients can access Urgent Treatment Centres through booking appointments through NHS111, or through General Practice, the ambulance service and walk in appointments.
The plan is for access to the Urgent Treatment Centre via NHS111 to become the default option and walk in attendances to reduce.
Patients who pre-book an appointment by NHS 111 should be seen and treated within 30 minutes of their appointment time.
“Walk-in” patients should be clinically assessed within 15 minutes of arrival, but should only be prioritised for treatment, over pre-booked appointments, where this is clinically necessary.
Following clinical assessment, patients will be given an appointment slot within two hours after arrival time.
Urgent treatment centres and NHS 111 should tell patients to self-care and use the community pharmacy whenever appropriate. (More info coming soon on patient self-care as key to Lincs Sustainability and Transformation Plan.)
If people do end up at the urgent treatment centre rather than the community pharmacy, they will be offered self-care management and patient education.
Centralisation of breast services at either Lincoln or Grantham Hospitals, with Lincoln the preferred option
Breast services are currently delivered at Lincoln County, Pilgrim and Grantham hospitals with a small number of patients seen in Louth Hospital.
Again, this centralisation would mean people having to travel further for these services.
Centralisation of Acute Stroke services
Acute stroke services are currently provided at Lincoln and Pilgrim Hospital.
The preferred option is to centralise acute stroke services at Lincoln Hospital. This is hugely contentious, as it means far longer journey times for people in the Boston area – and time is of the essence in treating strokes.
The evidence for centralising stroke services in cities is not particularly strong, and there is NO evidence that stroke services centralisation in rural areas is beneficial for patients. Save our NHS in Kent is currently fighting stroke services centralisation and has a mass of evidence to support their case. More evidence can be found in this ck999 blog post.
The other option that Lincs Sustainability and Transformation Partnership is looking at is to retain the current service at Lincoln and Pilgrim Hospitals but with an out of hours combined on-call rota being based at Lincoln.
Either way, the proposal is also to enhance stroke rehabilitation in the community across Lincolnshire, in order to reduce the length of stay in hospital from 14 days to 7 days.
Centralisation of women’s and children’s services
These services include obstetrics (maternity care), neonatal (care of premature or sick babies), paediatric (care of children) and gynaecology. These are all currently delivered at both Lincoln and Pilgrim Hospitals. Babies born pre 29-weeks and children under five who require surgery are all treated out of county.
There are two “emerging options”.
The preferred option
This is for Pilgrim Hospital to continue with a consultant led obstetric service, with the addition of a co-located midwife-led unit; and to continue with a specialist care baby unit for babies born from 32 weeks.
To downgrade Pilgrim Hospital paediatric services to a short stay paediatric assessment ward for children needing up to 23 hours of care; low acuity paediatric in-patient beds overnight, and paediatric day case surgery.
Lincoln Hospital to continue with a consultant led obstetric service with the addition of a co-located midwife-led unit and to have a neonatal unit caring for babies born from 27 weeks.
Lincoln Hospital to have a short stay paediatric assessment ward and paediatric day case and planned surgery.
Centralise paediatric in-patient beds at Lincoln Hospital
Keep the gynaecology services the same as now on both Lincoln and Pilgrim Hospital sites with clinicians working as one team across these two sites. What does this mean in terms of staff? Is there a team at each hospital at the moment? How would it work to have one team at two hospitals 26 miles apart?
The other option
This is to centralise consultant obstetric, neonatal and paediatric services at Lincoln Hospital, together with a midwife- led unit. And downgrade Pilgrim Hospital’s mother and children’s services to a midwife-led unit and short stay paediatric assessment ward at Pilgrim Hospital.
Centralise inpatient Haematology (Blood) and Oncology (Cancer) services at Lincoln Hospital.
These services are delivered in out-patient clinics and in-patient beds. They are currently provided at Lincoln, Pilgrim and Grantham Hospitals (haematology out-patients only at Grantham), with most care delivered at Lincoln Hospital.
Under the proposals, it seems that Grantham and District Hospital and Pilgrim would lose inpatient oncology beds. And Pilgrim would lose inpatient haematology beds. Meaning patients who need these services would have to travel Lincoln.
Haematology and oncology outpatients and day cases would continue to be provided from all three hospital sites. Chemotherapy and radiotherapy would be provided at Lincoln Hospital as now. Chemotherapy day cases will continue to be provided locally at Pilgrim and Grantham Hospitals.
Centralise elective (planned) and day case orthopaedic surgery and non-complex trauma at Grantham District and General Hospital.
This service is currently provided at Lincoln, Pilgrim and Grantham Hospitals, with out-patients, minor procedures and operations in the local community hospitals.
Under the Lincs Sustainability and Transformation Plan proposal, Lincoln and Pilgrim Hospitals would provide some day case surgery and planned care for those patients with complex needs.
(So it looks as if only routine patients would go to Grantham – which lacks an intensive care unit.)
But even routine surgery can lead to life threatening complications and it is not right to propose to centralise elective orthopoedic surgery and non-complex trauma at a hospital without an intensive care unit.
Outpatient services would remain at Lincoln, Pilgrim and Grantham Hospital.
Centralisation of this service in Grantham would worsen health inequalities. It would mean patients travelling huge distances to Grantham for planned orthopaedic surgery, instead of being able to go to their own district hospital. For people on low incomes this would cause serious problems.
Centralise elective short stay and day case General Surgery at Grantham Hospital
Again, centralising elective short stay and day case General Surgery at Grantham Hospital would mean patients travelling huge distances from all over Lincolnshire and worsen health inequalities
General Surgery mainly focusses on the stomach, gall bladder, small bowel, colon, rectum and anus. It also includes benign skin conditions and hernia. General surgery is currently carried out at Lincoln, Pilgrim and Grantham Hospitals, with more complex cases seen at Lincoln and Pilgrim Hospitals only.
Under this proposal, Lincoln and Pilgrim Hospitals would provide some day case/elective care for patients needing complex surgery. Outpatients will remain at all three hospitals.
Either remove medical inpatient services from Grantham and District Hospital or transfer them to Lincs Community Health Services
Medical inpatient services currently support urgent and acute patients in the Grantham A&E Department, on the in-patient wards and in the out-patients department.
One option is to have no medical inpatient services at Grantham Hospital. Diagnostics and outpatients would continue.
The other, preferred option is to maintain maintain inpatient medical services at Grantham Hospital and manage them as part of the local enhanced integrated neighbourhood team. More info about “Care Closer to Home” coming soon – please check back for link later.)