Dear Mr Kershaw,

We write to you as physicians and consultants in Acute, Elderly and Speciality Medicine, Radiology and Pathology at Lewisham Healthcare NHS Trust (LHNT).

In your draft report, you have proposed the closure of our Accident and Emergency department, and replacing it with an Urgent Care centre for patients not requiring admission to hospital. The consequences of this include the closure of the intensive care unit, coronary care unit and the acute medical and elderly medicine service of Lewisham Hospital. 

We would like to highlight major inaccuracies and flaws in the analysis in your report, and explain why your recommendation will disadvantage the health needs of Lewisham patients. 

Background to the Acute Medical and Elderly Medical Services at LHNT

We have an active and thriving medical department housed in the 2006 Riverside development. 36 patients per day are admitted on average in acute and elderly medicine, over 13,000 per year, which accounts for the majority of all admissions to the hospital. The average length of stay is 6.4 days.  LHNT was also one of first hospitals in London to gain full stroke accreditation. It has low hospital acquired infection rates, particularly C. Difficile and MRSA bacteraemia. We have recently been praised by the Care Quality Commission for respect for privacy and dignity in treatment of the elderly. We have consistently been among the Top 40 Hospitals in the CHKS rankings. http://tophospitals.chks.co.uk/assets/files/CHKS_2012_WMATH_5_Web2.pdf

Lack of Alternative Provision for Patients Currently Admitted to LHNT under Acute and Elderly Medicine

1. In other acute care settings

Medical patients currently seen at LHNT will be difficult to accommodate elsewhere if acute services are lost from the site. Surrounding hospitals will face an increased burden both in their A&E departments and in the medical wards, resulting in increased risk to patient care and potentially greater lengths of stay in other institutions. There is inadequate provision in the report of extra in-patient resources in these other institutions. 

In ‘A Picture for Health’ 2008, it was concluded that if Lewisham Hospital NHS Trust were to close their A &E department, 70% of the emergency patients who would have been be admitted to Lewisham Hospital would go instead to A&E at King’s College Hospital (KCH) or St. Thomas’ Hospital. These institutions already have capacity constraints, particularly in view of the centralisation of specialised services on those sites. The additional bed requirement was estimated to be in excess of 340 beds across the two hospital trusts. There will be an additional burden on Queen Elizabeth Hospital, Woolwich (QEW) equivalent to approximately 20% of the numbers admitted to LHNT. The closure of Queen Mary Hospital A&E in 2011 has resulted in an increased demand for inpatient services at QEW which has not yet been adequately accommodated.

2. Out of hospital

The report makes mention of a Community based Care strategy, but beyond a general aspiration for this there is no description of how this would be implemented, or any description of allocation of the necessary resources. There is no evidence given, beyond the anecdotal, for the assertion in the report that community based care can result in a 30% reduction in acute admissions to hospital. A similar assertion made in 2008 in ‘A Picture for Health’ has not been met with any reduction in the need for secondary care. Lewisham Healthcare NHS Trust, as a community-integrated organisation, is in any case already engaged with admission avoidance. Our COPD community and outpatient intravenous antibiotic therapy teams provide support for patients in their own homes to prevent the need for admission and our admission avoidance team have access both from the acute Trust and the community to consultant led bed-based rehabilitation. Our community and hospital heart failure nurses working together to support patients discharged from hospital and reduce re-admission. There is rotation of our staff through the community and LHNT, which helps staff. Although we continue to support fully the development of any initiative to enhance out of hospital care and care closer to home, there is no compelling evidence yet that this has had a significant effect on overall numbers of admissions – indeed admission rates have not fallen and the frail elderly population is increasing inexorably.

Furthermore, there is a strong likelihood of an increased length of stay if patients are admitted outside Lewisham;  residents of Lewisham Borough admitted to Lewisham Hospital have a 2.7 day shorter stay than patients admitted from other boroughs Excellent existing relationships with social services in Lewisham would be lost and not replicated in neighbouring boroughs.

Access to other acute sites for the population of Lewisham

The A&E departments of the Queen Elizabeth and Princess Royal Hospitals are not easily accessible from Lewisham. Car ownership in Lewisham is low, with 42.8% of

Households in Lewisham without access to a car or van, compared to an average of 37.5% in London. http://www.londoncouncils.gov.uk/search.htm?cx=012816060298198299354%3Aulbaum7l6aw&cof=FORID%3A11&ie=UTF-8&q=car+ownershipMany residents would have to take at least two buses and there is no train station nearby. Travel times to these A&E departments, and to those at St Thomas and King’s College Hospitals, are estimated ‘without traffic’ in the report and are unrealistically short for a densely populated urban area. Elderly patients from Lewisham will be disadvantaged since their friends, family and carers will have difficulty visiting due to transport.  Furthermore integrated teams will lose the benefit of a functional in-reach to facilitate early discharge or avoid admission. 

Urgent Care Centre and Patients Presenting with Medical Conditions

Our colleagues in the Emergency Department have already responded to your proposals. Specifically, they have analysed your estimate that 77% of patients currently seen in the A&E department who do not require admission could still be seen in a future urgent care centre. Their review is that the true figure is 30% or less (see https://www.savelewishamhospital.com/lewisham-emergency-department-says-no/)

In the setting of acute medical illness, GPs and patients usually do not know whether admission to hospital will be necessary in advance. For this reason, GP colleagues are unlikely to refer to an emergency facility (whether termed a minor injury unit or urgent care centre) that has neither the specialist skills to assess the patient, or the facility to admit that patient should that be necessary. Many who attend our emergency department are assessed by the expert medical team and discharged with plans for investigation and follow up. This would not be the case with a non-admitting emergency facility, where such expert opinion and full range of specialist investigation would not be available. Many elderly patients are rapidly assessed by the specialist elderly medicine acute team and are discharged with enhanced community support. These functions simply could not be substituted by extended nurse practitioners or general practitioners in a non-admitting facility without the support of specialist medical teams on site.

Effect on Outpatient Medical Specialties, Cancer

The draft recommendations suggest a drop of about 15% in outpatient activity if the proposed closures of A&E and medical wards occur at Lewisham Hospital. We predict a much bigger impact than this.

Patients with many chronic diseases such as asthma, sickle cell crises, COPD, epilepsy and inflammatory bowel disease have acute exacerbations requiring acute admission. The integrated care of these patients would be jeopardised if acute services on the site were lost. If they are admitted through other A&E departments, they will not be known to the physicians in these hospitals. Care would therefore be fragmented, with lack of continuity and reduced quality of care. Patients would naturally prefer to be seen in the outpatient departments of hospitals where there is an A&E, as they will then be known to their physicians at that hospital when they are admitted in an emergency. In many cases the first presentation of chronic illness is through an acute admission, and initial diagnosis is made by the specialty team at the acute site. Of new cancer diagnoses nationally, 23% come through as emergency presentations. This proportion is higher in deprived areas such as Lewisham where presentation with cancer is later. http://www.ncin.org.uk/publications/data_briefings/routes_to_diagnosis.aspx

For these reasons, without an acute medical service there would be a significant reduction in the number of outpatients at Lewisham Hospital. This implies that Lewisham Hospital would lose income as other trusts would increase their outpatient share. This loss would be substantially greater than that allowed for by the financial modeling in the report.

Impact on Undergraduate Medical Teaching and Post-graduate Medical Training in the region

Lewisham Hospital is well-regarded as a provider for undergraduate teaching and medical training. At a recent meeting arranged to discuss the educational and training implications of the draft report, Lewisham was commended for its record by King’s Medical School, the heads of the surgical and medical specialty schools and post-graduate deans. Currently, we are responsible for the delivery of clinical teaching to over 400 KCL medical students per annum and it is unclear how this could be re-provided elsewhere within SE London. In addition, we have 240 post-graduate doctors in training with universally excellent feedback through national and local surveys. Closure of acute services has a significant detrimental effect on training which cannot be realistically provided in the setting of a non-admitting emergency facility or by an elective surgical centre; experience elsewhere in London (e.g. in Epsom and Queen Mary’s Hospital, where most trainees have been withdrawn) has confirmed this.  

Conclusion

The recommendation to close the acute medical services is unsound, based on evidence which is unfounded and on inadequate consultation. There is no robust alternative provision for acute medical needs, either by other acute providers or in the community. We have grave concerns for the safety of our patients and the impact on their quality of care if these proposals are carried out.

Yours sincerely,

50 Dr’s