Response from GPs in Amersham Vale Practice, Lewisham to Matthew Kershaw, TSA , on his proposals to downgrade Lewisham Hospital.
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We speak as a group of doctors with over fifty years combined experience of working in Deptford and New Cross – one of the most deprived areas of Lewisham and the UK.
Our practice notes the attempts in the consultation documents to try to minimise the impact of the proposed changes, implying that people in Lewisham will not notice much difference. We disagree and are of the opinion that the proposals amount to the closure of Lewisham Hospital as a DGH. Not only will it lose it’s A+E, but also its admitting medical, surgical and paediatric wards, its ICU and very likely its maternity. This therefore represents a very large reduction in availability of a wide range of important local health services. Such a significant reconfiguration required a proper health inequalities impact assessment, high quality clinical evidence, involvement of local clinicians and public in the specific plans and an adequate consultation period. None of these conditions has been met in this rushed and ill-thought out proposal.
We are opposed to the proposals because they:
- increase risks to our patients;
- adversely impact on a very deprived community, worsening health inequalities;
- will destroy excellent local services that our patients depend on
- are based on wrong calculations about use of A+E and erroneous assessments of patient flow;
- fail to take account of the increased demand on other hospitals for which no adequate plans are being made
- are dependent on a community based strategy that is insubstantial and unrealistic and which will not make up for the proposed reduction of 400+ in hospital beds
- will destroy collaborative relationships within Lewisham between primary, secondary, community and social care, damaging both patient care and attempts to improve efficiency and contain costs;
- will have a serious detrimental effect on GP training.
Health inequalities
Lewisham is the 14th most deprived borough in England and our practice is located in one of the most deprived parts of Lewisham.
Our practice patients are typically of low income, relatively young, with a high birth rate, higher incidence of birth complications, higher prevalence of ill health in children and relatively high rates of chronic conditions such as diabetes. Our elderly patients are more likely to live alone. Few families own cars and most rely on public transport.
The impact of losing acute services in Lewisham will fall disproportionately on the most deprived sectors of the community – those who have the greatest health needs and the least resources. Factors like increased travel times and associated costs will therefore hit such patients harder than people with more resources. Given our young population and high birth rate, the loss of acute paediatric services (including paediatric A+E) and maternity will be particularly detrimental to our patients.
No equalities impact assessment was done to inform the TSA proposals. It is proposed the HEIA will be done after the consultation is finished and will not be made public. This is a shocking failure and makes a mockery of the purpose of HEIA which is to inform the development of proposals from the outset.
Flawed modelling of A+E use and patient flows
The modelling of how we as GPs and our patients use A+E and will use other resources is not based on an analysis of actual use. There is a schematic notion that only those who were admitted really needed an ED, and those not admitted did not need an ED and could be managed by GP and ENP. This is simply not realistic. In practice we often refer patients to A+E for a specialist assessment and after that the patient my not be admitted, but that does not mean they did not need that assessment. Especially for GPs, who are generalists, we often need a second opinion from someone more specialised. Common examples include the baby with acute bronchiolitis, the person with abdominal pain. Such patients often manage to get to Lewisham A+E by private or public transport due to its proximity. We would not refer such patients to an UCC to be seen by a GP with no more knowledge or skill than we have. Patient choice means that individuals requiring an emergency referral will undoubtedly end up at KCH or GSTT; it certainly won’t be QEH.
This means that several aspects of the TSA modelling are wrong:
1. The numbers needing to attend an A+E are far higher than 22%
2. GPs will not refer patients they are unsure about to an UCC
3. The patient flow from north Lewisham will be to St Thomas’s A+E or to Kings, and not to QEH.
4. patients who need admitting will be admitted to STH or to Kings and not to QEH.
Travel times
The travel time assessments you use are totally unrealistic. The times you quote from the TFL website are for conditions when there is no traffic. This does not reflect reality – the reality that our patients will have to deal with if they need hospital care. The travel times are also based on average times across SE London and do not relate to the actual time it will take patients from our area to travel to QEH – at least two buses and over an hour’s journey, much more if there is heavy traffic which is usually the case.
If the financial modelling depends on patients going to QEH then it is unsound, as that is not where patients from Lewisham will go. Our patients will go to Kings College Hospital or St Thomas’s Hospital, and not to QEH.
Lack of capacity in other hospitals and risks to patients
We are also very concerned about the apparent lack of planning for other hospitals in the area to meet the increased demand from Lewisham patients. We know already that QEH A+E is not coping with demand, that it often breaches the 4 hour target by as much as 20%; that Kings cannot take more maternity referrals from Lewisham, that ambulances have been diverted to other hospital further away because there are no beds in local hospitals. We worry that patients will be put at risk both by delays in getting the urgent care they need, and by being admitted to hospitals that lack the resources to cope with them. Patients will experience a decline in overall quality and accessibility of care and will be put at risk. For the most seriously ill urgent cases we fear there may be some serious avoidable adverse events and even deaths. This is a concern especially if we lose full local maternity services.
Maternity
Our practice has a high birth rate of which a higher than average proportion are high risk births. Most of our patients choose to have their babies in Lewisham as it is local and has a good reputation. This has developed over the past few years especially since the opening of the new Birth Centre. We do not support either of the maternity proposals in the TSA document. The closure of the maternity would reduce quality, access and choice for our patients and put them at risk because other maternity units just would not be able to cope with the dispersal of 4000-5000 births a year. The alternative of a stand alone obstetric unit, without medical, surgical or ICU back up is simply unsafe and therefore unacceptable.
Unrealistic community based strategy
It is surprising how much the TSA proposals seem to depend on the success of the community based strategy, with a large part of his draft proposal devoted to this. And yet the strategy is insubstantial, with words like ‘vision” and “aspiration” used repeatedly. There are no concrete plans, costings, resources, timescales or anything that would give one confidence that this strategy will be implemented. Furthermore there is not one bit of evidence provided that such a strategy will reduce hospital demand at all, much less by the hoped for 30%. One can only conclude that this is not a genuine initiative but a device to deflect concerns about how the demand for patient care will be met when Lewisham Hospital closes as an admitting hospital. The TSA plans will mean the net loss of 400+ beds in SE London. If there is no drastic drop in demand then where will the patients who need hospital care go? In order to avoid answering this there is the spurious idea that community based care will meet that need. Not only is there no evidence that this can happen, but even if it were possible it would need serious resources, planning, training and piloting of different models. etc. , and it would take time. It would make sense to put this strategy in place first, then as demand for hospital care fell it would then be appropriate to close beds, not the other way round.
Part of the community based strategy is predicated on GPs increasing their workload by 20% with no extra resources. This seems to mean GPs seeing more patients, more quickly. Not only is there no evidence that this would reduce demand for hospital care, the opposite is likely to be the case. Rushed GPs are more likely to over-treat, over-investigate and over- refer, because with less time its better to play safe and practice defensively, and also easier to conclude the consultation quickly with such actions.
Furthermore, if GPs are to be managing more and more of the complex patient with long term conditions, they need more time, not less time. The Royal College of GPs (RCGPs) advocate appointments of at least 15 minutes and this means we need more GPs. This will need increased investment in primary care and a lead in time for training more GPs. The resources for this have not been identified in the TSA strategy.
GP training
As a training practice we, and our patients, benefit from the high quality of GP trainees attracted to Lewisham. The decision to remove acute medicine, surgery and paediatrics from Lewisham will mean that Lewisham GP trainees will no longer be able to train in a local hospital. They will be sent to different hospitals which will damage the coherence, and the attractiveness of the scheme. The TSA proposals will jeopardise the Lewisham training scheme. As a training practice we are very concerned about this, and also concerned that the TSA proposals fail to address the issue of medical training, as if it were unimportant. The Lewisham scheme attracts high quality trainees, many of whom choose to stay to work in Lewisham, thus replenishing our primary care workforce with excellent young doctors who improve the quality of care for Lewisham patients, but who also have a thorough understanding of the respective roles and relationships of primary, secondary and community care, having worked in an environment which fosters this understanding.
Relationships
There are good relationships between practices and Lewisham Hospital which have developed over time and which enable better planning and co-ordinated joined up working, to the benefit of patients. This practice is part of Lewisham CCG which has built on this relationship to improve care pathways and responsiveness. The closure of Lewisham as a DGH will end all such relationships. It will be the end of collaborative commissioning and joined up working. It is the very opposite of what the government claims to be promoting, and for which Lewisham was a flagship example. It cannot be replicated with multiple providers of secondary and community care across a huge geographical area.
In summary, the doctors at Amersham Vale Training Practice strongly oppose the TSA draft proposals to close Lewisham A+E, close its acute medical, surgical and paediatric wards and ICU, and downgrade or close its maternity service.
Dr Surinder Singh
Dr Louise Irvine
Dr Magda Branker
Dr Sam Wessely
(GP partners, Amersham Vale Practice, Lewisham)
