Reconfiguring Hospital services in Shropshire.

Keeping it in the County Dec. 2010.

Response prepared by D. Sandbach.

The argument for rational configuration and long term sustainability.

Rational Configuration.

The policy of maintaining two main hospital sites in Shropshire at RSH and PRH is in my opinion the
least rational option available to the people of Shropshire, mid Wales and the local NHS Trust
Boards.

The consultation document, under option 3 and 4, makes it perfectly clear that:

A) A single DGH is the best option see option 3 page 10.

B) The second best option is option 4 – all major inpatient and emergency activity occurring on
one site.

Both these options are dismissed in the consultation document due to the current financial climate.

I believe dismissing these two rational options is not in the best long term interest of health care in
Shropshire.

I am sure that setting a single site hospital as a strategic goal and delivering this goal over a period of
years is the right thing to do and is possible even though the UK’s current economic climate is not as
good as it has been in the recent past.

The consultation document states:

“In many ways, this would be an ideal solution. We would be able to design new facilities from
scratch. We would have the most up-to-date equipment in purpose-built accommodation.
We would also have all our staff and services together on one site, which would make it easier for us to use
1
them where they are needed most at any time. ”

SaTH and the PCTs were formally notified that the idea of a single site was technically and financially
viable in September 2009:

Recommendation 3: To NOTE that all three options for the 2020 single site have the potential to be
technically and financially feasible2

1
Source Keeping it in the County page 10.
2
Source Agenda Item 4. 22 September 2009 T&W PCT Board meeting.

1
The consultation document fails to give a comprehensive reason as to why a single site DGH in
Shropshire is a sound idea. An idea that is supported by local clinical personnel and by external
clinical advisors.3 By avoiding this issue the public are kept in the dark about the wider health care
benefits of such a strategic policy.

Sustainability.

 The financial climate in the UK is not as good as it has been in the past. The need to deliver
effective stewardship of scarce public resources is vital to keeping hospital services in the
County.
 Demographic change will continue to place ever greater pressure on financial allocations.
 Pressure to deliver clinical improvements and improved labour productivity in the NHS will
increase.
 Pressure to have increased medical specialisation will continue.
 The potential for the private and voluntary sector to increase their involvement in treating
publically funded patients will put pressure on SaTH to rationalise services in order to
compete and provide a modern 21st century service for the public.

Given the factors noted above I have concluded that a two site hospital system in Shropshire is not
a sustainable clinical or financial proposition in the medium to long term.

If we can all agree that a programme of centralising services on one site is in all our interests
(clinical, public health and political) then we can rest assured that our hospital service in Shropshire
is in a strong position to weather the up coming changes in the way health services are delivered in
this country.

The case for one DGH.

Option 3 Page 10 Keeping it in the County-

“In many ways, this would be an ideal solution. We would be able to design new facilities from
scratch. We would have the most up-to-date equipment in purpose-built accommodation.
We would also have all our staff and services together on one site, which would make it easier for us
to use them where they are needed most at any time.”

In order to provide some context to this statement I have prepared, using published Annual Reports
for 2009/10, a high level analysis of SaTH’s performance i.e. a two site hospital service compared
with two centralised acute hospital services.

The assessment compares similar but not identical organisations.

3
National Clinical Advice Team received in January 2009
Source http://www.sath.nhs.uk/Library/Documents/ournhs/090917-NCAT%20Final%20Report.pdf

2
The assessment is broad brush approach but taken as a whole confirms what is only common sense
i.e. that to run two hospitals doing more or less the same core activity on each site is more
expensive and less clinically efficient than running one hospital.

Please note the assessment in no way implies that the staff of SaTH are not doing their very best to
deliver good clinically sound hospital services for the benefit of their patients, they are where they
are – working in an inefficient two site system.

The table on the next page is a comparison between three Acute Hospital Trusts:

 Shrewsbury and Telford Hospitals NHS Trust (SaTH)

 The Countess of Chester Foundation Trust (CoCH)
 Royal Wolverhampton Hospitals NHS Trust (RWH).

All three organisations are in the same service area i.e. the provision of District General Hospital
services. There are some differences e.g. RWH is a designated Regional Heart and Lung centre. The
catchment area for RWH is 330,000 the catchment area for CoCH is 250,000 where as the catchment
area for SaTH is 500,000.

3
 Performance analysis of one split site DGH SaTH and two single site DGHs CoCH / RWH.

Comparator SaTH CoCH RWH Comment

Income from Income from patient care activity at RWH is 9%

Treating £242,156,000 £158,148,000 £264,077,000 higher than SaTH
Patients

Activity SaTH produces 32% less service than RWH. If

508,547 427,000 750,000 SaTH were on one site the public could expect
an activity rate of 675,000p.a.

Beds SaTH has the highest number of beds. As a

890 600 706 single site organisation SaTH could reduce its
bed compliment.

Staff Calculations prepared for SaTH show that it has

4201 3000 5000 around 120 too many beds this is because the
beds are on two sites.

Average cost The average price of service activity from SaTH

per item of £476 £370 £352 is around 28- 34% more than the CoCH and
activity RWH.

Ratio of staff to SaTH labour productivity is 18% below that of

activity 1 : 121 1 : 142 1 : 150 the CoCH and 19% of the RWH. This is because
they are not concentrated on one site.

Ratio of staff SaTH has the worst staff to bed ratio, 5.6% less
per bed 4.72 : 1 5:1 7:1 than CoCH and 33% less than RWH.

Activity per bed SaTH has the worst utilisation ratio by at least
ratio 571 : 1 711 : 1 1062 : 1 20%.

Ratio of SaTH has the highest ratio of beds per

catchment pop. 561.79 : 1 416.6 : 1 467.2 population 34% more than CoCH 20% more
to beds than RWH

Ratio activity to People in the SaTH catchment often get their

catchment pop. 1.017 : 1 1.70 : 1 2.27 hospital services out of county – the cross
border leakage is around 10% or from
providers other than SaTH in Shropshire.

4
The figures above clearly show what is instinctively obvious i.e. that the operation of a twin site
acute hospital services is not in the best interest of people living in the SaTH catchment area because
having two hospitals in the county doing similar work is:
 clinically is inefficient
 expensive and wasteful of resource
 an impediment to delivering more and better health care.

The difference in the unit cost of service provision shows how much more expensive a dual site
service is; this is very important since it translates into money being spent on fixed and semi variable
over heads rather than staff, clinical quality and increased over all service productivity / delivery
levels.

Translated into activity terms these figures suggest that a single hospital site in Shropshire could
provide the population with between £67.8 and £82.3 million pounds worth of extra health care (28
- 34% of £242,156,000) this translates into 183,000- 231,830 extra health service contacts in the
acute hospital service or some extra resources for other health related activity e.g. community and
mental health care.

Put another way, the pay and non pay cost of the community service in Shropshire e.g. Community
hospitals, community nursing etc is around £38 million per annum4. If the Acute hospital service was
centralised Shropshire as a community could afford to have more community based beds and
community based, in home, services provided by community doctors, nurses and therapists caring
for people in or close to their home.

Capital Funding to support change.

In the near future SaTH will become a Foundation Trust in its own right or become part of an existing
Foundation Trust. Access to capital for developing services will become simpler because Foundation
Trusts are not subject to Delegated Limits for Capital Investment:

“NHS Foundation Trusts are not subject to delegated limits for capital investment set by the
Department of Health.”5

4
Source
http://www.shropshire.nhs.uk/Documents/docs_common/Publications/Board%20Papers/2011/25%20January
%202011/9.1%20Board%20Report%20-%20Financial%20Performance%20-%20combined.pdf
5
Source
http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_080
865.pdf

5
Having spoken to Mr. J. Mann from the Department of Health’s Capital Investment Branch I
understand that a Foundation Trust can access capital as long as the project can be afforded, FT’s
have the autonomy to proceed with capital projects.

The statement in the consultation document “In the financial climate now facing the nation, that
money (£350 – 450 million) is not available” is a defeatist and very pessimistic position given:

a) A Foundation Trust access to private capital is a possibility.

b) The Government is committed to “capital spending remaining higher in real terms than it
has been on average over the last three Spending Review periods.”6

I believe that we should aspire to a single site DGH in Shropshire and I think the public should be
asked to give their views on the following three models of care:

Model 1. Possibly with Women and Children’s services

As proposed in the consultation document. staying at RSH and surgery transferring to PRH
from RSH. NB the £60 million price tag quoted in
the consultation document for relocating the
Women and Children’s service at RSH is OTT7/8.

Model 2. If executed over a period of several years this is

Concentrate all major inpatient and emergency an achievable goal.
activity on one hospital site and deal with
planned activity at the other.

Model 3. Best option needing vision and perseverance to

Provide one DGH for the county at RSH / PRH or achieve.
new build between the two existing sites.

6
Source HMG Treasury Departmental settlements: http://cdn.hm-treasury.gov.uk/sr2010_chapter2.pdf
7
Sourcehttp://www.pat.nhs.uk/uploads/20100603_231%20New%20£32m%20w&C%20building%20complete
%20DRAFT1.pdf
8
Source http://www.pat.nhs.uk/uploads/20101021_A3%20NMGH%20generic%20poster%20new.pdf

6
I believe that the consultation process in 2009 and 2010 was / is inadequate because both
documents lacked detail e.g. no comprehensive demographic or epidemiological assessment, lack of
detail in terms of an impact assessment.

In short no one in their right mind would make a judgement call as to the wisdom of the favoured
option verses the alternatives. If these documents were a prospectus for investors on the stock
market they would bomb – no one would put their money in because of lack of basic information.

Public Transparency and a Modern consultation process.

In line with the Governments views on Localisation I feel we should try to widen the process of
participation beyond the public meeting road show method and focus group meetings.

I think that the following consultation programme would be better:

 Prepare a consultation document with all necessary public health, demographic,

epidemiological clinical and financial information in one place agreed before hand with
Shropshire Council and Telford and Wrekin Council. This document to be put on line as a
reference source and made available in public libraries.
 Prepare an option appraisal of the three principle options noted above. NHS management to
leave out any reference to a preferred option. Issue as a paper and online consultation
document.
 Place all working documents used by NHS planners on line for the public to view.
 Place all written consultation comments and any NHS replies on line.
 Provide a moderated online public discussion area plus a Q & A Facility.9
 Tap into the massive democratic resource we have in the county and ask each parish / town
council Chair person to:
a) Have the consultation document discussed at a public parish / town council meeting.
b) Attend a NHS run meeting to give verbal and written feed back from their community.

At the end of the process the SaTH Board will:

 Not be in a position where anyone can claim a “done deal / fix” has been agreed.
 Have a good idea of what ideas and concerns people have.
 Have open public evidence to show SC and T&W scrutiny committee what people think.

9
The NHS has an on line facility which is more about giving the party line e.g. Mr. Cairns letter to the press
than sharing corporate the knowledge and public views.
http://www.ournhsinshropshireandtelford.nhs.uk/news/News-Archive.aspx

7
  Have use the Internet to engage as widely as possible with the public (68% of Shropshire
people have home access to the Internet. 100% have access via the library service.)

 Be in a position to make an informed decision which is transparent and is as fair as possible.

“bring people and communities with them through the process of change so that they have a
strong mandate to act and take difficult decisions on behalf of local people and
communities”10

10
Page 6
http://www.shropshire.nhs.uk/Documents/docs_common/Have%20Your%20Say/FINAL%20Involvement%20to
olkit%20Nov%2010.pdf

8
The remainder of this paper is a critique about SaTH and the PCT’s approach to consultation and lack
of openness. It gives some insight as to why I have made the comments I have on page 7 and 8
above.

 The debate about replacing the Maternity and Paediatric Unit is welcome but a bit late in
the day. Around four years ago a structural report about the RSH maternity building was
prepared for the SaTH Board. There were a number of recommendations like do not drill
holes in the structure, worry about asbestos was noted, as was movement in the building.
Only now do the public know that this building should be demolished.

 In the consultation document of 2009 the proposed options under consideration were:

“Option 1 RSH - Level 2 A and E with acute surgery, inpatient paediatrics, obstetrics and neonates”

“Option 2 PRH - Level 2 A and E with acute surgery, inpatient paediatrics, obstetrics and neonates”

At that time the public were led to believe that option 1 was the right thing to do in the interest of
all the people in the SaTH catchment area. The tune has now been changed.

The option appraisal on these two options showed the following:

Option 1 RSH Option 2 PRH

Non Financial 694 634

Benefit Score
Capital £m 18.2 47.1
Revenue 0.9 2.2
Impact of
capital £m
Construction 2 3
period (years)

Of the18.2 million capital in RSH Option 1, £7.5166 million (41.3%) was to be spent on re-providing
Paediatric services at RSH, the fact that the whole of the Women and Children’s Unit at RSH needed
demolishing (as now declared by SaTH during public meetings) was hushed up.

 Had the fact about the need to entirely replace the Women and Children’s Unit been
declared in the 2009 consultation document we would have had a different consultation in
2009 /10 because the capital figure under RSH Option 1 would have been at least as much
as under PRH Option 2.

 It now appears that a similar scheme as that which was proposed at PRH in 2009 at a cost of
£47.1 million will now cost £28 million in 2010.

 Keeping Women and Children’s services at RSH would have cost, in 2009, £18.2 million and
now in the 2010 consultation document it will cost £60 million.

9
Capital figures quoted in the 2009 and 2010 consultation documents tell diametrically opposed
stories.

 £47 million to move Maternity etc to PRH in 2009 – conclusion too expensive.
 In 2010 £60 million is needed to keep Maternity services at RSH - conclusion too expensive.

 The numbers and conclusions appear to move in line with what ever party line SaTH et al
choose to take. On the face of it behaviour like this suggests a behind closed doors decision
making dynamic as opposed to a public, rational and evidence based dynamic.

 It would be fair to say that the current consultation document has some odd claims about
what is and is not feasible.

“The cost of this scheme (and some other changes to buildings that would be necessary as
part of the preferred option) is estimated to be £28 million - a figure that can be afforded.
The cost of rebuilding the maternity unit at the Royal Shrewsbury Hospital site is estimated
to be close to £60 million, which is not affordable.”

I found the figure of £60 million to be a bit excessive.

A quick search on the Internet has provided some details of the situation else where in the country.

Women and Children’s Unit Manchester.

In Manchester a new Women and Children’s Unit was opened in the summer of 2010 it cost circa
£32 million11.12The new development is of a similar size as the one we need to replace the building
at RSH. The Manchester Unit can cope with a maximum of 5,500 births per annum13. The unit in
Manchester will provide a full range of high quality services to women, children and babies
including:

Brand new Children’s Day Surgery Unit

Kids’ Observation and Assessment Liaison Area (KOALA)
Children’s Inpatient Unit
New antenatal ward
New postnatal ward
New delivery suite/labour ward and operating theatres
New Neonatal Unit/ Special Care Baby Unit (SCBU)
New midwife-led birth centre

Artists’ impression of the new Women and Children’s Unit North Manchester Hospital

11
Source
http://www.pat.nhs.uk/uploads/20100603_231%20New%20£32m%20w&C%20building%20complete%20DRA
FT1.pdf
12
Source http://www.pat.nhs.uk/uploads/20101021_A3%20NMGH%20generic%20poster%20new.pdf
13
Email from E Stringer Interim Head of Midwifery North Manchester General.

10
  Had the Manchester capital cost, which is an actual rather than estimated spend, been
noted in the current consultation document there is a possibility that two options would
have been put forward for public consideration in the 2010 consultation document i.e.

Option 1: the favoured option as per the current 2010 consultation document.

Option 2: the reverse of option 1 with vascular, upper gastro-intestinal surgery and colorectal
surgery going to PRH with a part day Paediatric assessment ward and out reach Paediatric cover
provided from RSH to PRH

 The fact that Option 1 & 2 above are both viable must raise serious doubts about the rigor
applied to preparing the 2010 consultation document.
 Both the October 2009 and December 2010 consultation documents were / are inadequate
for strategic corporate decision making purposes affecting a vital public because they avoid
and fail to answer the most fundamental question - can we continue to have a dual system
of Acute services in Shropshire?
 A comparison of the two consultation documents (2009 & 2010) clearly shows that NHS
management has an “emergent” approach to strategic planning. The emergent approach to
strategic planning is some times described as “flavour of the month” planning14 which can
be a very risky management approach to planning when dealing with major long term
decisions with life and death implications for around 500,000 people.

 It is very unfortunate that the picture of what the hospital service should look like in the
future has not been properly articulated in the current consultation document. Indeed the
idea of considering or explaining the future beyond a quick fix model is studiously avoided
and dismissed on the grounds of difficulty in obtaining the necessary capital.

14
Guide to Business Planning. Authors: Friend & Zehle. Pub.- The Economist. 2004. Also know as “pick a
victim” planning.

11
  I would agree that the latest proposed configuration of hospital services does have some
internal intellectual logic in it since there is what could be described as a ‘shared pain’
philosophy of planning evident in the 2010 consultation document. The model also helps
SaTH to secure a solution to some of its immediate safety problems and licensing issues
whilst, at the same time, positioning it to centralise services further on at some time in the
future.
 If one DGH is the ideal long term strategic position as noted in Option 3 of the consultation
document then the democratic process dictates that SaTH should be clear about its
intentions on this matter. To identify the ideal and not state ones long term position about
achieving it is a recipe for continued distrust and speculation.15 16
 Given that the decisions SaTH and the PCTs want to make will affect the lives of thousands
of people and involve vast amounts of hard earned tax payer money we must demand to
know what the end point is to be for the hospital service in Shropshire, Telford and Wrekin.
 If the NHS management does not know where it wants to end up in the longer term how can
the public give informed consent to a series of tactical departmental moves and be sure
these moves are sensible and use scarce resources wisely in the context of a wider plan to
stop services leaving the county?

15
Please see Code of practice on Openness in the NHS:
http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_402
9974.pdf
16 st
Shropshire Star 31 January 2011 2Battle to save services ‘needs to be more aggressive’

12