Henry responds

This is a long one….

Back at the start of February, I challenged Cllr Henry Smith on his Campaign 4 Pease Pottage Hospital proposals. The basic gist of it is here.

After a bit of banter on Maidenbower.org.uk (I came in around page 12) I boiled it down to seven questions. Henry finally (about a month later) has answered them.

The questions are shown in bold. Henry’s answers in italics. My response is in green.

  1. What are the credentials of the professionals who produced the report? (as a supplementary, can I ask whether any of them are affiliated to the Conservative Party or if they have interests in the Private Health sector?)

    The working group set up to consider the project included clinicians, a former senior DOH official, a retired local authority chief executive and private sector executives. The paper was drafted by Adrian Brown, a former managing Director of Tarmac plc’s Management Division, which has been responsible for building, financing and running many large public sector projects including several large acute hospitals. Preliminary discussions were also held with other companies including Healthcare Projects, a healthcare company with experience of managing some of the largest new hospital projects in the NHS including Barts & The London NHS Trust, University Hospitals Coventry & Warwickshire and South Derbyshire Acute Hospitals Trust Derby. They found our proposals innovative and they assisted by modelling the travelling times for a new hospital at Pease Pottage. Discussions continue with other interested parties.

    Mr Brown, who also served as Chairman of the Surrey & Sussex Healthcare NHS Trust, has no affiliations with any political party, and has no interests in the Private Health sector.

    That addresses who Mr Brown is (I couldn’t work it out from a google search). It also seems that private companies are being consulted, although I suppose we can’t know too much about their involvement if it is ‘commercially sensitive’.

    It would have been nice for C4PPH to have been up front about who authored their proposals, a list of three names at the bottom is almost meaningless.

  2. Why has training and the issue of Royal Colleges guidelines not been addressed, particuarly as it affects the assumption on a viable catchment area?

    Patient numbers and throughputs need to be accurately modelled and an suitable model of care developed working closely with clinicians, other stakeholders and the Royal Colleges. This is planned as part of the second phase of the project. There is no uniform model of care suitable for every region. Of particular relevance is the BECAD model developed by the DOH and also models of care used in other European countries, especially those with lower population densities.

    Except, of course, that the UK has a fairly high population density, and this part of the South East is hardly desolate. It may well be appropriate to apply BECAD to areas like North Yorkshire or the Peak District, but we are not there.

    Of course, the short answer is ‘No, but we hope that when we do, they don’t completely change things, or worse still rule out our assumptions’

  3. How exactly were the estimated figures arrived at – particularly the running costs one?

    Capital costs were based on the actual completion costs of two 500 bed acute hospitals in the Midlands with an adjustment applied to bring the cost base up to current costs. Frimley Park NHS Trust was used as a basis for operating costs as its scope of services is similar to those proposed, it is well run (Foundation Trust), operates from a single site and is in the south east close to a Motorway in an area of high employment and relative affluence. As a comparator, Rotherham Foundation Trust was also looked at. It is a similar hospital but located in the north east where employment levels and relative affluence can be expected to be somewhat lower. There was virtually no difference in the cost base. Both hospitals have c 700 beds so costs were adjusted accordingly.

    I’m pretty sure that is not the ‘exactly’ I asked for. It adds little more than the document provides itself, that they adjusted the figures. I wanted to know how the adjustment worked.

  4. Are there local factors that differ between here and Camberley that might effect running costs and the viability of this plan – such as staff turnover/availability, employment base, etc?

    See answer to Q3.

    That doesn’t cover the question. This area has historically poor history regarding NHS finances. There must be some root cause, and it goes back further than 1997. Before that, Crawley was threatened with closure, Horsham was downgraded. Given that the NHS will be paying the revenue bills, how can we be sure that whatever it is that is wrong won’t just be continued?

  5. Why propose private management for a major hospital including A&E? Where is a similar model already successfully employed? Why not? The private sector has been encouraged to run many aspects of public services both in the NHS and in other sectors. Diagnostic & Treatments Centres (DTCs) e.g. Redwood at East Surrey Hospital which is run and managed by BUPA delivers excellent care and value. ITCs (Independent Treatment Centres) are owned and run by the private sector to treat NHS patients. It is only suggested that this option be considered. Also suggested is that the option of a not-for-profit trust be considered to own the hospital if the conventional NHS PFI route is not followed. This will allow the substantial profits made bythe PFI providers to be used to improve patient care.

    There are currently no hospitals in this country where the A&E function is under private management. ITCs have so far been small, with no more than a simple ‘cuts and bruises’ clinic rather than a real casualty department. They also rely on elective private surgery to work profitably, and around here I suspect that there is a bit of competition for that (Gatwick Park? Redwood?). Combined with the idea that this will be pretty much a District General hospital, which will mean much of the throughput will be NHS rather than private, I wonder if this will actually be ‘substantially profitable’. Of course, if the PFI / private health management company make a loss, what happens? Does the NHS (ie: John Q Taxpayer) pick up the tab? Or do services suffer?

  6. Other than spelling mistakes, what errors in the report have been missed?

    The basis of the report is clearly set out. So does that mean there are no errors in it? Or that he can’t find any?

  7. Why can’t the Bagnall proposals not form the basis for a campaign? The Bagnall report provided a valuable insight into healthcare options several years ago. Healthcare has moved on since then and there is more scope for innovative thinking. We have shown how a modern hospital can be provided (albeit somewhat differently than the standard NHS model) to treat local patients. The model proposed provides state-of-the-art healthcare, a strong element of local control and management, no additional financial burden on the NHS and employment opportunities not only for the hospital itself, but for the other healthcare related facilities which it is anticipated will be attracted to the site.

    However, Bagnall basically concluded that the area (North Sussex & East Surrey) could only sustain one major General hospital. That’s why Crispin Blunt hates it, because the top recommendation was to move that one hospital from near Redhill to near Crawley.

    The trends in healthcare have not altered substantially in the last 5 years, although perhaps the financing has. We knew in 2001/2 that there would be less need for people to spend a long period on a ward before and after surgery. We knew then that emergency care was more dependent upon the speed with which a paramedic could arrive on scene and what they were capable of.

I have to say, I don’t find these answers very convincing. There is something to these proposals, but the one area that really concerns me is that they appear to have been knocked up in order to back up the campaign, rather than the other way around. As a result, the plans have not been thought through, and the proposers are still waiting for the ‘next phase’ before they find out whether it’s actually viable from the point of view of training accreditation for medical staff.

They don’t like it up ’em!

I posted the previous article on the Maidenbower website here (second post down), as it is a place where you can publicly ask Henry Smith and others questions.

You can see how well Tory Councillors respond to a bit of detailed criticism if you look further on. A mixture of personal attacks, ignoring the question and getting basic facts wrong.

I am still not angry.

Hospital Campaign built on thin air?

When I first heard about the Campaign for Pease Pottage Hospital, I was suspicious, it sounded just like an opportunistic attempt by local Tories to jump onto a bandwagon.

After some time, the campaign has produced a document, which they say backs up their case and anyone who disagrees is clearly just trying to land political blows.

Having now read the extensive (!) 7 page proposal document, I am even more sceptical about the Smith-Maude campaign.

First of all, I spotted at least two spelling mistakes. Now, that may mark me out as a pedant, but they are clear and they are evidence that the document was not properly proof-read. One wonders if any of the numbers are also incorrect.

Next, it is full of assumptions. Firstly, that the acute healthcare spend in Horsham PCT per person is uniformly applied across the other areas covered. Secondly that the percentage of that to be spent at the new hospital would be 75%. Thirdly that the refinancing (what we call interest) rate would be 7%. Fourthly, that East Surrey Hospital will be affected but will still be tenable if it widens it’s catchment along the M25 (but no consideration of the knock on effects to the East or West of Redhill) – oh, but if it isn’t the new hospital would be able to cope and the people of Redhill and Reigate would be happy.

There are lots of numbers, but some are given as ‘of the order of’, or ‘indicative’ (which means that they are not accurate estimates) and others are absolute, despite seemingly having been derived from the earlier estimates. The operating cost is given based on Frimley Park, but no more local hospital ‘given their state of turmoil’, and because that is a larger hospital it is scaled, but the scaling has not been enumerated. Are there local factors which differentiate this area from Camberley such as housing pressure?

Some startling omissions as well. Nowhere is training mentioned. Nowhere does it refer to Royal College guidelines. Why should it? Because the Royal Colleges suggest that for training to be of sufficient value, a unit must have a decent catchment area, of around the 400-500,000 range. In order to attract employees, a hospital really wants to be recognised by the Royal Colleges, as most doctors want to move up the ranks and gain experience. The proposed 300,000 catchment area might be too small, and this was pretty much the same problem that Crawley Hospital had in the first place. Find me an acute hospital which has lost accreditation from a Royal College and where that service is not under threat (or already gone).

Also, this would not be a PFI hospital, it would be privately managed, rather than being run by the NHS and leased from a PFI vehicle, according to the proposals. Do we have such a hospital in the UK? Would the managers seek to carve out part of the hospitals facilities for lucrative private care? What will the costs be to the NHS of oversight of a privately run hospital? Will the operating company be allowed to make a profit? If it makes a loss, or suffers financial strain, what are the guarantees that services will be maintained?

Bagnall’s report was far more detailed, and we were able to see the ‘working out’. I supported the Bagnall Plan because it was well considered and the proposal was a viable 776-bed hospital. The C4PPH proposals are, going by a document of seven pages, less grounded in detailed research and less sustainable.

Local Issues – 1. Hospital

Right. The Hospital. This is a big issue, and has been for years. Longer than people realise, I think – the original Hospital campaign was set up to get one built, which it eventually was in 1961. In the wrong place. That’s where the trouble really started.

West Green is not a bad place for the hospital, but it is far from perfect. Because the site was small, they built up. There were always rumours of expansion, either over Ifield Road or on the old Primary School site. However, in the mid-80’s the last time that more investment was put into the Health infrastructure, Crawley lost out. Big time.

Redhill got its old hospital replaced by East Surrey. That wouldn’t be a problem on its own, but the real kicker was the building of the Princess Royal to the south of Haywards Heath. At the time, it would have been better to replace Crawley with a major hospital to the south of the town, Pease Pottage would be (and still is perfect). However, political pressure from local notables (you’ll see who they are, they have parts of PRH named after them) led the Tory government to build in their areas.

Ten years later, the NHS under the Major Government was talking seriously about closing Crawley down altogether. That was the first time the recent Hospital Campaign got active. Luckily, the threat was withdrawn and the Trust merged with East Surrey. Unfortunately the new trust seems to have been dogged by management and financial problems ever since.

By 1999, when the changes that everyone is complaining about were first officially suggested, things had changed for Health. Whereas a General Hospital serving 100,000 to 250,000 people used to be suitable, providing enough opportunities for training doctors and consultants, nowadays the Royal Colleges are saying that 400,000 to 500,000 people is the right catchment area. This presents a problem for the area between Croydon and Brighton – three Hospitals cater for an area which is too small – if they want to be training hospitals (and they do – or they won’t attract any decent young practitioners). The PRH was moving towards Brighton, and Crawley and East Surrey shared the same Trust. And that Trust got to the state where it had to concentrate services on one site, or face losing training status for both.

Without a new build, it is (unfortunately) obvious that East Surrey has better scope for improvement than Crawley. And with East Surrey and PRH so close by, it is very hard to justify a brand new hospital at Pease Pottage. That doesn’t mean that it doesn’t make sense to do it, but it makes it very hard to convince the bureaucrats in the NHS that this is a good idea. They have far more weight than a local MP ever will (which is just as well, as the problems caused by politically motivated hospital building got us where we are now…). It was essentially the Trust, the regional NHS (and then the Strategic Health Authority) that made the decisions. The Health Secretaries and Ministers of the time were simply acting on advice.

When the local SHA looked at the Bagnall Review, they duplicated the financial work, so reducing the attractiveness of a new build. They then said any new build would have to be financed by the local Primary Care Trusts. The Surrey PCTs voted against any such help, as did the Horsham PCT, while Crawley PCT stood out alone, and so even though they wanted to help, they couldn’t act alone.

So, the Hospital Trust carried on with its plan. To make matters worse, they didn’t put it into practice very well. Something that had apparently been planned for 5 years (the transfer of A&E) happened as if it was planned on a Sunday evening on the back of a fag-packet. Lack of communication with the local Ambulance service meant that too many minor injuries were sent to East Surrey, resulting in queues. There have been a few changes at the top, but the problems of managment and finances just won’t go away.

So, who do people blame?

The Council. Well, this is completely silly. First of all the Borough Council has almost zero responsibility for Health, and so by law is actually not supposed to provide a hospital. What it has done, as long as I can remember, is to support the building of a new Hospital (to the point of offering a site), oppose cuts at Crawley, organise at least one of the demonstrations held in the town. Several councillors (including myself, the current Leader Chris Redmayne and two who lost their seats in 2000 – Chris Mullins and Bill Ward) were actually involved in the Hospital Campaign, until we were forced out because of the ideological intransigence of the SWP-inspired organisers. So, no. The Council is NOT to blame.

The local MP. Laura only really made one mistake. In 1999, instead of instantly and unequivacolly (sic) coming out against changes, which would have been universally popular, she decided to look at things in detail. In the end, she did come out against the changes, but by then the rumour-mill (fed by the trots again) had it that Laura was in favour. Despite the fact that she was instrumental in getting the Bagnall Review, people think that she did nothing. I know exactly what Laura has done, the lobbying on our behalf, and unfortunately it was never going to be enough. The decisions were effectively made already, and no MP could have made much difference. In fact, our previous MP, Nicholas Soames, did virtually nothing when the complete closure was mooted in the mid-90’s. Perhaps because he knew he was going to stand in Mid-Sussex by then.

The Government. There is some responsibility here, after all, they hold the purse strings for the NHS, they approve or deny changes like moving A&E or building a hospital. Certainly Alan Milburn did nothing to assist, apparently ignoring letters from locals (well, not replying anyway). However, nationally I think that they have done a lot for the NHS. At least they are building new hospitals, at least waiting lists are falling, at least Cancer survival rates are improving. While they didn’t do what we wanted and give us a new hospital, they did put extra money in to improve Crawley and East Surrey.

I can understand why people blame the local Council or MP. It is easy. So easy to point at a politician because they are there to represent you. It is far harder to point the finger at a quango, a team of bureaucrats, a Royal College, or whoever.

Oh, and half the people that complain now were nowhere near the campaign when it really needed support, back in 1999-2001. To those that were, you will remember the work that was put in, and the disappointment we felt each time a decision went the wrong way. To those that weren’t – perhaps you are complaining so much to offset your own guilt?

By the way – Henry Smith didn’t get involved with the Campaign until he had already been selected as candidate for the 2001 election. While some Tories were around, or did give support (Richard Burrett and Robert Lanzer), his ‘intervertion’ stunk of opportunism. And if he had become our MP, he’d have had the same weight as Laura – virtually none – while annoying the established Tory MPs in Reigate and Redhill, who are happy that East Surrey was not downgraded in favour of Crawley.

(ooh, controversial, huh?).