As the Member of Parliament for Chelsea and Fulham, I have close connections with both Chelsea & Westminster Hospital and Charing Cross Hospital. Like any other resident, having lived in the constituency since 1990, I have unexpectedly found myself at both A&E departments over the years. My daughter was born at Chelsea & Westminster Hospital in 2006, and my son at Queen Charlotte’s Hospital in 2007. I campaigned hard against previous plans to downgrade services at Charing Cross, which emerged when I was still a local Councillor, and have been a member of the hospital’s Friends group for fourteen years. Likewise, I am one of the vice presidents of the Chelsea & Westminster Friends group. My constituents are heavy users of both Chelsea & Westminster and Charing Cross Hospitals.
2. Consultation structure
The purpose of the proposed changes is to reduce the number of Accident and Emergency units in North West London from nine hospitals to five. At the outset, I believe this to be a very substantial change, effectively halving the number of A&Es. Whilst each A&E can be assessed in isolation, the critical factor must also be the cumulative impact of closures, especially the impact of the four closures on the remaining five units. My belief is that, given the radical nature of the change, this would be almost reckless to carry it out in one process, without any proper assessment of the impact of so many closures on the surviving A&E units.
The other general point I would make is that for local people, hospital reconfigurations and reorganisations have come and gone in our area, but what counts for local people is the excellent quality of care in this area of London, which has been the case since at least 1990. Indeed, NHS North West London, who are leading the consultation, is itself on the point of abolition. Hammersmith Hospitals Trust has similarly had a shortened life, and the future of Imperial College Healthcare NHS Trust appears very much in question, only a few years after its establishment. For local people, what counts is their hospitals and their facilities, particularly A&E, which should remain at both Chelsea & Westminster and Charing Cross.
Returning to the local configuration, given my close association with both Charing Cross and Chelsea & Westminster, I am appalled that the consultation gives no consideration to allowing both to continue as major hospitals. The premise of the option structure is that one or the other must be downgraded, with a clear preference expressed for Option A, which reduces Charing Cross to a small local hospital, shorn of its accident and emergency department and all major services.
I am not making a judgement on the clinical case for having more specialisms on fewer sites, but I note the concerns expressed in the Rideout report commissioned by Hammersmith & Fulham Council regarding both out of hospital care and the sequential 'funnel' used in the options appraisal, which does not make allowance for the size and quality of the hospitals placed in pairs. A binary choice between Chelsea & Westminster and Charing Cross is a false choice. Because they are paired, no analysis has been undertaken of the ability to meet the stated clinical objectives while keeping both open as major hospitals.
The out of hospital strategy, although welcome, appears insufficiently developed to be replied upon to take demand away from a smaller number of accident and emergency departments. Until it has been implemented and shown to be successful, it would be premature to plan the closure of entire sites. Equally, some of the assumptions around urgent care centres seem speculative and do not reflect known patient preferences.
Regarding the need to find savings, I recognise that the so-called Nicholson challenge began under the last government, and that all parties are committed to finding £20 billion of efficiencies to meet the demands of a growing, and ageing, population. This is balanced by the rising budget for NHS North West London, reflecting the present government's ring-fence around NHS spending. Efficiencies and clinical improvements can go together. I am not persuaded, however, that Option A will deliver improvements for my constituents.
3. Chelsea & Westminster under Option A
It is essential that Chelsea & Westminster should remain a major hospital with a full accident and emergency department. Nevertheless, Option A fails to reflect the impact on Chelsea & Westminster should the A&E at Charing Cross close, even if capital costs are incurred by expanding the current site. That site is severely constrained, placing a limit on what can be added. The numbers also assume that the urgent care centre at Charing Cross will continue to take as many patients as it does presently. This seems unrealistic, as the UCC operates by channelling patients away from the accident and emergency department; many go there intending to access the A&E, or because they want the reassurance that it is available on site, and such patients are likely to travel to Chelsea & Westminster instead. I fear that the influx from Fulham, Hammersmith, and beyond, would create detrimental pressure on the service provided at Chelsea & Westminster under Option A. Chelsea & Westminster have stated that they will cope with the additional admissions, and have outlined plans to expand their A&E on their rather constricted site, but when I met with management there in September, I did not find the arguments particularly convincing, other than Chelsea & Westminster needing to say they could cope, otherwise their lack of confidence would be seen as an argument for Option B.
4. Charing Cross under Option A
Charing Cross Hospital is a world-class research and teaching facility. It is one of the few hospitals to have a sufficient number of beds under the consultation criteria and hosts regionally important services such as the hyper acute stroke unit. Given its size and quality, it seems extraordinary for it to be downgraded to become a minor local hospital, unrecognisable from the facility that exists today.
It is hard to ignore the underlying financial motives of Imperial College Healthcare NHS Trust, which has been struggling with a large deficit and has made persistent attempts to remove services from the Charing Cross site. The most recent saw the loss of vascular surgery. I was first elected to Parliament after highlighting the previous threat to the hospital, in 2005, and it is not hard to discern the reason for Imperial's hostility. Its finances would be significantly improved by operating on two sites rather than three, not to mention unlocking a substantial capital receipt from any land disposal. Imperial would retain all these proceeds if its ambition to become a foundation trust is realised.
The extent of the proposed downgrade can be seen in the pre-consultation business case documents. Of the 5.38 hectare Charing Cross site, a mere one hectare would be retained for use as a local hospital and urgent care centre. An illustrative map shows that only a small corner of the site would be required and the main building would be entirely vacated. Given the height of this building and of the accommodation blocks nearby, both of which form a significant precedent in planning terms, the listed disposal value of £10.2 million per hectare massively understates the true market value. It disguises the fact that Imperial could expect to receive a receipt in the hundreds of millions, yet have provided no indication of the purpose for which a receipt higher than £44.6 million would be used.
Although the loss of services beyond the A&E is referred to in the consultation document, it does not make clear that the entire site would be redeveloped and the hospital, as it is known, closed. This is regrettable and calls into question whether the consultation has engaged frankly with the public.
The nearest accident and emergency departments would be at Chelsea & Westminster and St Mary's, Paddington. It is not clear that increases in either 'blue light' or 'private' travel times have been properly considered. The analysis is derived from averages in the HSTAT database, and average travel times in central London can be highly misleading because of the variable nature of congestion, which can bring streets to a standstill. No predicted routes have been provided, suggesting that the impact of route restrictions on match days at Chelsea FC, and from emergency roadworks on arterial routes, is unknown. Ambulances need to reach a patient swiftly before they can be stabilised and then have a defined window of time in which to reach an A&E before patient outcomes deteriorate. The limited travel analysis does not allow one to conclude that Option A is safe.
Overall, there is a disproportionate impact on Hammersmith & Fulham, which will be left without any accident and emergency provision of its own. The worrying gaps in the consultation material are also demonstrated by the Rideout report's inability to determine whether the 20,000 extra homes planned for the borough are included in the demographic assessments made by NHS North West London.
5. The four tests
The government has been clear that plans for hospital reorganisation should be developed locally, by PCTs and the emerging commissioning groups; consulted on; and only then be referred for approval. When asked, ministers have explicitly affirmed that no decision has been taken on the Shaping a Healthier Future proposals, which will be judged against four tests. These tests were set out by the former Secretary of State for Health, namely that:
- There must be clarity about the clinical evidence base underpinning the proposals.
- They must have the support of the local commissioners involved.
- They must genuinely promote choice for patients.
- The process must have genuinely engaged the public, patients and local authorities.
I have already raised doubts in relation to the first test and will return to the second. While the development of out of hospital care will promote choice, the choice between major hospitals will obviously be reduced. It is perhaps wrong to speak of having a 'choice' between accident and emergency departments as, in an emergency, the nearest is always preferred; however, the further distance is detrimental for all those who use Charing Cross. A choice is maintained between hospital trusts, but it is unclear why sites run by one trust could not be transferred to another, if this would enable more to remain open.
NHS North West London has engaged to some degree with the public, appearing at meetings and running events, but awareness has rested on the efforts of local authorities and campaigners. Local press coverage, while welcome, is restricted by limited circulation and adverts in the press are not equivalent to direct mail. Moreover, the opaqueness of much of the consultation material, and the impression it creates of a foregone conclusion, makes the genuineness of this engagement process questionable. I am also informed that health scrutiny committees on the local authorities affected have found it difficult to get proper answers to their questions.
6. GP Commissioners
There has been an unsatisfactory blurring of the distinction between the primary care trusts and the shadow clinical commissioning groups, which assume PCT responsibilities next year. While it appears that this will be solved by a reconstitution of the JCPCT, the Hammersmith and Fulham CCG has been unable to clarify whether its members serve as delegates or representatives of GP practices, and how its stance should reflect the wider views of general practitioners in the locality. It seems this is a problem common to all eight CCGs involved. Despite this ambiguity, there appears to be no mechanism to survey the views of ordinary GPs within the consultation, although some have been forthright in opposing the plans. This must call into question the ability of the proposals to pass the second test.
I urge NHS North West London to think again. There are options available that have yet to be examined, but which allow both Chelsea & Westminster and Charing Cross to continue as major hospitals. A solution should not be compromised by the particular organisational difficulties faced by Imperial, or by its desire for a substantial capital receipt from the disposal of the Charing Cross site.
The halving of A&E units in North West London is simply too abrupt and radical a change. The impact of the closures on the surviving units has not been properly assessed.
Like me, my constituents use and rely on our local NHS hospitals. It is clear they do not want to travel further to an accident and emergency department, and they are right to be unpersuaded by the case that NHS North West London has made during the consultation. Patient safety must come first.
Greg Hands MP
Member of Parliament for Chelsea and Fulham