Dear Mr Kershaw

I wanted to put some final comments to you before the end of your consultation period on Thursday. I am writing as an individual, and as a paediatrician who has worked in Lewisham for the last twenty years. You have received the considered views of our Directorate paediatricians.[1]

To put the Lewisham community context to the forefront of my comments:

Lewisham is the 16^th most deprived local authority area in England out of 326 authorities. Greenwich is 19^th most deprived. Compare the impact of your proposals on Lewisham for example with that on the far less deprived Bexley (180^th) and the far more affluent Bromley (217^th).[2]

In your proposed major reconfiguration of services, which exceeds the remit of the “Unsustainable Provider Regime” process, the probable impact on our deprived and vulnerable community will be massive. Every assumption you make must be revisited and reviewed through the lens of the relative needs and resources of the local population. Every change in accessibility to a service, any barrier that is created will result in the destruction of local pathways, disruption to local services, impact of difficulties in travel etc – and is a direct challenge to the already deprived populations of Lewisham and Greenwich.

You have failed to take this into account. Your process is thus fundamentally flawed and unjust and fails dramatically within the context of the relative deprivation and vulnerabilities of Lewisham and Greenwich when compared with their more affluent neighbours Bexley and Bromley.

Your own Appendix H heralds the inevitable inequitable impact of your proposals, however  you have not allowed for further examination and public scrutiny of these issues before the closure of your consultation. To remind you of your own demographic evidence:

• Lewisham and Greenwich      share high levels of deprivation and associated vulnerabilities
• Lewisham (16^th)      and Greenwich (19^th) have the highest ranked level of      deprivation compared to Bexley (180^th) and Bromley (217^th)      – ranked amongst 326 local authorities in England
• Of the four boroughs of      Lewisham, Greenwich, Bexley & Bromley:
  • Lewisham has the       youngest average age
  • Lewisham & Greenwich       share the worst life expectancy for males;
  • Lewisham has the worst       life expectancy for females
  • Lewisham has the       highest disability rate (20.4%) amongst adults 16-64
  • Lewisham and Greenwich       have the highest population of people from black and minority ethnic       communities

And, particularly in the context of children & young people:

• Lewisham has the       highest birth rate                                 
• Lewisham has the       highest population of children under 5  
• Lewisham has the       youngest age profile of children under 16
• Lewisham has the 2^nd       highest teenage conception rate in London & joint 3^rd       highest in England
• Greenwich (19.3%) and       Lewisham (8.4%) have the highest projected growth in population (Bromley, 4.6%; Bexley 3.5%) over 2012-22

 Health and Equalities Impact Assessment
You as TSA have not performed any health & equalities impact assessment prior to the end of the consultation period. Your Appendix H scopes what should be done, but this has not been undertaken in time for it to inform public consultation.

 Your TSA proposals have therefore been developed without knowledge of their potential risks and likely impact. This is surely a gross act of omission on your behalf. You have confirmed that the HEIA assessment will only be completed after the closure of the consultation period. This means that the Secretary of State for Health will receive the HEIA as part of your final proposals whilst neither the population of Lewisham nor Lewisham Healthcare Trust will have had the opportunity to make any comments based on the assessment.

Although you regretted this fact when you met me at St Andrews Centre 16^th November, you stated that there was no alternative, despite the fact that millions of pounds have been spent on the TSA process. I cannot accept this. It simply is not good enough. Your proposals should not have been developed without the information derived from an impact assessment.

 You have entirely avoided public scrutiny on this aspect of the process, adding weight to my view, and that of others, that your proposals are indeed a back door route to service reconfiguration.

 Misleading arguments on emergency services

Notwithstanding the exceptional needs of the local community, you and your colleagues have used arguments for centralisation of services for stroke, heart attack, vascular and major trauma emergency as the justification for the loss of Lewisham’s A&E as your road map to better care. You ignore the vast majority of urgent medical situations of the local population, many of which are linked to deprivation and the specific health needs of a multi-ethnic population such as Lewisham and Greenwich, a few examples being:

• Sickle cell crises
• Emergencies such as bleeding in       early and late pregnancy
• Sick babies and children
• Diabetes emergencies

Very few would argue against the benefits of centralised care for specified health emergencies. But you have hidden behind that to deceive the public into believing that all emergency care must be centralised. No serious assessment of health impact on loss of access to A&E healthcare for Lewisham residents has been done: travel estimates are based on travel at times when there is ‘no traffic’ (Table 4, p25). Your proposals erect barriers to access to local services for our vulnerable population and you will harm the health of both Lewisham and Greenwich communities.

No health equalities assessment = no credible proposals

Consultation with clinicians

I regret that you also have hidden behind a claim that you have the engagement and support of local clinicians: in reality you have used local clinicians. We were invited to workshops to be told what we could and could not talk about. We were given wildly unrealistic examples of health care systems plucked out of context from around the world, but with no health economic analysis that made them relevant to south east London.

Community based care solutions, laudable in themselves, have not been costed against evidenced health outcomes. Where is the evidence that your investment will give better health outcomes and at the same time cost less? You have asserted this without evidence and claimed clinical engagement as a cover, implying clinical consensus when there was none.

Community-based care and integrated pathways

Lewisham Hospital IS part of the Lewisham community.

Lewisham Hospital is right at the heart of Lewisham. Our integration with our community services is less than three years old and is already beginning to show very positive benefits. Our relationship with local GPs, the local authority and commissioners is way ahead of most areas. You are about to tear apart partnerships that are beginning to deliver better and better community-based care in practice, only to replace them with theoretical risky experiments. You propose to shut down our ED and admission wards, essential elements supporting the clinical safety of our community-based care, and offering continuity of care in the centre of our community.

You have not modelled patient flow for children. Children who could not attend Lewisham with the closure of ED will most definitely pour towards Kings. Our carefully nurtured integrated pathways between hospital and community will be in ruins.

Maternity services
Others have written detailed responses.[3] But once again, your proposal to remove maternity services from Lewisham (Option 1) and break the relationship between midwives and obstetricians and local community midwives and health visitors. We are able to support teenage mothers access antenatal care at Kaleidoscope, close to the hospital. We provide Family Nurse Partnership support to vulnerable mothers, with close work working closely with GPs, our hospital local to the community, and Social Care and other agencies. Hospital midwives and community health visitors have build close relationships to support mothers and young babies with strong communication and information sharing. You must not jeopardise these crucial aspects of quality, access and safety. Option 1 places our safeguarding of children and vulnerable mothers at grave risk.

Your neglect of children
I should be surprised that you have neglected 20% of our population in your document – children. However, this terrible omission repeats a typical experience I have witnessed over 20 years as consultant paediatrician. Those that know no better assume that children’s needs are little different from adults, and can therefore be tagged on as an afterthought.

Those that know better cherish our children as our future and realise how vulnerable they are, especially in an area of deprivation such as Lewisham. Those who work in Lewisham have chosen to take on that challenge to work in our community and help it achieve its full potential. We seek to offer excellent services locally where they are needed and where they are accessible. That is why we have built up: excellent acute children’s ED and inpatient services, excellent outpatient services with close links to tertiary specialties; the unique Kaleidoscope Centre bringing together the partnership of community health, mental health (Lewisham CAMHS), Lewisham Education and Social Care; and exceptional special needs nursing and home-care community nursing teams. Our mental health colleagues are working so hard with our children’s ED and inpatient to support children and young people in mental health crisis – these relationships will also be destroyed.

• It has been hard to create and develop our children’s partnerships over the last 10-20 years. It is only too easy to destroy them: your proposals will do that.
• Any major work that has ignored children entirely, as you have done, has failed and should not be worthy of consideration.

 I ask that you think again.

Yours sincerely

Tony O’Sullivan

Director of Service, Directorate of Services for Children and Young People

(In personal capacity)