Dear Mr. Kershaw

We write as a practice to convey our deep concerns about the proposals produced by the TSA office for the healthcare provision of the people of South London and in particular for the population of Lewisham where we work. We are entirely opposed to the loss to this area of the comprehensive, safe, high quality and effective services currently offered by University Hospital Lewisham.

We note the first principle of your report that patients’ interests always come first so that they have the necessary access to the services on which they rely. We do not see in the report any convincing evidence presented that proves a case for the closure of an acute medical and surgical admitting facility at Lewisham. Indeed we are clear that the changes you propose are only offered as a solution to the ‘underlying financial challenge’ you cite in your foreword. They do not relate in any way to your stated first principle.

You have said on BBC television that you do not want to undermine the clinical and quality improvements that have been made to local health care provision. The loss of acute services at Lewisham for seriously ill patients requiring hospital admission will lead to a serious loss of efficiency and local responsiveness. Closer integration can only occur with communication and relationship building. Relationships carefully built up in recent years between Lewisham GPs and Hospital Consultants and between medical teams and Social Services will be lost and links between the acute admitting hospitals (QEH, KCH or PRUH) and Lewisham GPs and Social Services will not approach this model of close integration. We consider there to be a high likelihood that this will result in admitted patients having longer lengths of stay, thereby increasing overall costs to the sector. Fragmentation of care is perhaps the biggest pressure facing every modern health service and is at the root of rising costs, poor quality of care and rising health inequalities. What evidence do you have that your planned closure of acute medical and surgical beds at Lewisham, the former in particular occupied by older patients with complex medical and social care needs, will not lead to expensive fragmentation of care?

In another example of integrated care, local work between GPs, consultants and nurses on care pathways for patients with Chronic Obstructive Pulmonary Disease has led to significant reduction in admissions. It will not be possible to replicate these pathways across three separate admitting Trusts in your suggested configuration.

Nothing is mentioned in your report of the opportunity costs for the 70-80 families daily whose relatives will be transferred to units at considerable distance from their homes. The additional travelling times quoted for the people of Lewisham do not bear any resemblance to the experience of our patients in using public transport at peak travel times in this part of London. What health economic instrument did you use in your assessment of opportunity costs for the population of Lewisham? What evidence can you provide which shows that clinical recovery times will not be affected if visiting by relatives is reduced by a lack of accessibility?

We consider that downgrading Lewisham A&E to an UCC will lead to more than expected patient flows to KCH and not to QEH. In the absence of plans to invest in greater capacity at KCH this would be a clinically unsafe scenario. What evidence do you have that Lewisham residents will choose QEH if they consider they have a condition requiring emergency hospital admission?

We are very concerned to learn that your report’s financial modelling is based on an estimated 30% reduction in secondary care workload resulting from the implementation of a Community Based Care Strategy. These suggested savings are based on totally unrealistic assumptions.

Your report cites as evidence the possibility of a 25% increase in GP capacity by increasing the minimum number of appointments offered per week. This would be entirely unachievable without a significant increase in primary care clinical staff (GPs and nurses) in which there is no planned investment. The increasing complexity of managing multiple long-term conditions in primary care has resulted in the pressing need for even longer consultations. The Royal College of General Practitioners has stated that there is an urgent need for GPs to spend ‘Longer with patients to deliver evidence-based, effective health interventions, to prescribe safely, and to allow those patients with multiple-morbidities who need more, time to have it.’ How does the Community Based Care Strategy take account of the recommendation by the RCGP that GPs spend a minimum of 15 minutes (rather than the current normative 10 minutes) with each patient?

In another QIPP suggestion, a figure of 20% reduction in referrals is quoted for ‘Incentivized referral management systems’. Limiting referrals by incentives is highly controversial mainly because the concept is unethical and may result in choices not being made according to clinical need. Referrals can be reduced but this drop if grossly over estimated. 

The studies quoted as evidence for the possibility of large savings from a new Community Based Care Strategy are isolated pilots without proven generalisability and the true effects of these interventions are bound to be much smaller when wider pragmatic implementation takes place. In addition, it is unrealistic to expect any additive effect between these multifaceted service changes. What statistical methods have you used to combine the effects of individual studies to predict a combined effect size equivalent to a 30% reduction in demand for secondary care services?

The hugely important area of integration between mental and physical health care is absent from your report. You may be aware that current policy highlights poor access to health services for people with mental illness. We are concerned your report does not make clear whether Lewisham residents will have an acute psychiatric facility co-located on the Lewisham Hospital site. Where will psychiatric patients at the Ladywell Unit receive their care under the suggested arrangements should they develop acute medical or surgical emergencies? Where will Lewisham residents with mental illness requiring admission receive their care should the land on which the Ladywell Unit be sold as a short term financial strategy? These patients, because of their social isolation and often associated disadvantage, deserve comprehensive services located close to their places of residence and not in facilities far removed from their community.

We are convinced that the plans you outline in your report will lead to worsening health care for our patients. We consider that the people of Lewisham deserve a comprehensive set of hospital services (including acute medical and surgical beds and a fully functional maternity unit) co-terminus with their local council and local Clinical Commissioning Group. These will minimise the fragmentation of care which under the current suggested plans will lead to rising costs, poor quality of care and rising health inequalities.

We look forward to your answers to our questions.

Yours sincerely,

Sydenham Green Group Practice.