Nurses warn Epsom and St Helier downgrade would put even more strain on 'overstretched' services in south-west London

The letter is addressed to the Surrey Downs Clinical Commissioning Group Board which is meeting next Friday, May 17, to decide whether to back the proposals drawn up by the Better Services Better Value (BSBV) team.

It says the concerns of tens of thousands of its members, healthcare experts working across the area, have been effectively ignored.

It believes the proposals fail to fully take into account pressures on community services and the impact of a rapidly expanding elderly population.

From finance and transport problems and the likely impact on St George's Hospital's already overstretched accident and emergency department, the RCN letter argues that the current proposals have not been properly thought through.

And it questions why no pilots are planned to trial the proposals, warning that "irrecoverable local healthcare damage could be a permanent consequence" of going ahead with these proposals.

Read the full letter below:

Dear Claire and the Surrey Downs CCG Board,

I am writing to you today, prior to your Board meeting on the 17th May to discuss the Better Services Better Value (BSBV) proposals.

I am Chair of Staffside at Epsom & St Helier NHS Trust and chair of the Outer SW London Branch of the Royal College of Nursing (RCN).

Unfortunately I cannot attend your meeting on the 17th as I am away, but as Claire knows, I have worked clinically in Epsom A&E for the past twenty one years and ask on behalf of our RCN members locally that you take into consideration the following information and concerns before coming to a decision.

From BSBV’s inception we have asked to be represented in the work streams as we have some ten thousand nurses and health care assistant members working in the BSBV catchment area. However these requests have always been denied meaning that there has only been a token nurse or other non medical clinician in the largely doctor led work streams.

Elected and representative bodies such as the RCN have been largely ignored. Where is the partnership working here as recommended by the DH? Now that the proposals have been published we see all sorts of problems for the local health economy caused in part, by failure to engage and listen to clinicians such as ourselves, who work on the frontline in our hospitals, in the community and in the private sector where healthcare is delivered to the local population.

Amongst RCN concerns are:

• That large groups of health professionals that are part of the multi-disciplinary health team have been ignored by the BSBV team in the whole process:

• Over emphasis on a medical model and leadership of changes. Epsom & St Helier NHS Trust see thousands of patients each year who are not registered with a GP and who are in hard to reach healthcare groups. This model doesn’t appear to do anything to support them. Indeed they will probably do worst, because there is now nowhere for them to go.

• Much of the proposals assume community services are in place but clearly District nurse numbers are falling and community and social services are already over stretched, at breaking point or non existent. With an ever expanding elderly population, which Government figures suggest will see over five million 85+ year olds in the next five to ten years, compared with one and half million today, provision needs to be expanded and hospital staff know all too well that currently there are not enough social care places locally leading to expensive discharge challenges. The proposals appear to show there is no credible plan to provide social care against the budget provided.

• There are no plans to pilot the proposals first so if they don't work there is no plan B and irrecoverable local healthcare damage could be a permanent consequence. With such a lot at stake here both financially and health and safety wise for our patients is this a risk you as commissioners are prepared to take?

• Lack of consultation of local residents – although ‘listening exercises’ were undertaken only much targeted groups were invited and we would argue not representative of the local population or clinicians other than doctors. We again asked to be involved but were not invited. The short time frame Epsom was given in coming into the proposals also leaves us questioning how meaningful engagement has been.

• Capacity issues - Epsom & St Helier saw 140,000 A&E patients or one every three and half minutes last year and as you will be aware these numbers continue to rise year on year. Many patients tell us they struggle to access their GP service in a timely manner because of opening hours and unavailable capacity in appointments. Epsom & St Helier are in the top four London A&E’s for seeing treating and discharging patients within the four hour target. Colleagues at St George’s walk in centre tell us that early in the morning there is often a queue of people waiting outside the building to access services. Do we really want to send our patients to that pressurised environment that can’t meet it’s 95% target?

• Lack of insight into the impact these proposals will have of the local health economy. The uncertainty of two local hospitals running down services, risks the loss of highly skilled and experienced staff to other areas of London, forcing up bank and agency costs and detrimentally impacting on CCG health budgets and local patient care. We all have to pay our bills at the end of the day; these proposals give thousands of local staff no sense of job security. Out of hospital care would have to improve significantly to breach the gap caused by these proposals within a shrinking health budget. It is hard to see how this will be done without detrimentally affecting the quality and experience of our patients.

• In the decision weightings BSBV plan to use, there is very little recognition of the quality of services at local hospitals, so a failing hospital such as Croydon can keep its services even though they fail some of their key performance indicators. Whereas a succeeding hospital, such as Epsom and St Helier, that has turned around historic debt is to be downgraded.

• Travel blight - If Epsom & St Helier are downgraded there will be a huge hole in Surrey and outer south west London where there is limited emergency medical cover. Frail elderly patients would be forced to travel into grid locked inner London boroughs, pay exorbitant parking fees, if indeed there was any capacity for parking, or rely on public transport which for Epsom end will be particularly difficult out side of main weekday working hours. How is this a better service for our local population? Ambulance staff at Chris Grayling, MP’s recent meeting talked of dangerously long journey times from parts of Epsom & St Helier catchment area, which would breach the ‘Golden hour’ for best possible patient outcomes. They also indicated that journey times had been ‘widely underestimated’ by BSBV.

• Finances appear to be one of the main drivers for these proposals. If they go ahead it is unlikely that the long promised rebuild at St Helier will go ahead. Instead money would be wasted knocking down new or recently upgraded A&E departments, Maternity and Paediatric units to accommodate the tens of thousands of patients that would have to travel into inner London to use these already stretched services. Is this really affordable? Why spend money on hospitals that are out of the patient’s catchment area? Why not develop local services and bring back the lucrative work that GPs and private enterprise have taken away from the hospitals and detrimentally impacted on our finances? Let’s have a level playing field here. Indeed its poignant the £11.4m BSBV spend thus far could keep both our A&E’s running for a year or more. Epsom and St Helier have significantly turned round their finances and are on track to be in a positive balance in two to three years time.

If the CCG wants any of the BSBV proposals to work we would suggest that the GP contract needs to be completely revamped to meet the demands that will suddenly fall at the surgeries front doors, but as that is unlikely to happen we would ask that you vote to reject the proposals in their current format and keep using our improving services which are local to you and much appreciated and rated by the patients we care for.

We look forward to hearing your decision on the 17th.

Yours sincerely,

Mike Smith, RN, DipN, BSc (Hons), Cert Ed Charge Nurse/ Emergency Nurse Practitioner

Mike Smith, Lead RCN Steward/Chair of Staffside Epsom & St Helier University Hospitals NHS Trust