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BRA AGM 2007

Unanswered questions after lacklustre PCT presentation

Wendy Lockwood opened a gap between herself and her audience at last month's BRA AGM (above) the moment she opened her mouth. Lockwood works for the Surrey Primary Care Trust (PCT) which, since last autumn, has been running NHS provision for Bookham and elsewhere.

The first crack opened when the audience learnt her title – 'associate director for public engagement'. Most people whose job involves manipulating public opinion are happy to say they're a public relations director. In today's NHS, it appears, such honesty isn't an option.

But then Lockwood spent much of the rest of the presentation translating herself into English. Some of it was merely well-sounding piffle without any roots in reality – 'the future hospital', or 'programme for change', 'expert patient programme.' Parts of one of her slides could have been in Albanian: 'GPOOH', 'WIC', 'UCC', 'HOSC', 'PPIF' and 'LVOS'. But when she got round to the 'virtual ward' some of it began to sound faintly scary.

Surrey PCT (SPCT) was formed last October 1 by merging five former Surrey PCTs – North Surrey; East Elmbridge and Mid-Surrey; East Surrey; Surrey Heath and Woking; and Guildford and Waverley.

SPCT doesn't run hospitals. It buys those services in by using the hospitals and other health providers – GPs and community nurses – as contractors. SPCT's budget is about £1.3 billion to cover a population of 1.2 million people.

SPCT is 'one of the few PCTs that has improved,' Lockwood told us. Not difficult. The largest new PCT in the country, it began with debts to match, and its improvements in medicine management have not been driven solely by the need to deliver happier patients. They 'helped us save some money', she reported.

Patronising platitudes
The BRA had invited Lockwood to tell its AGM about this and Surrey PCT's other challenges, not least how it justified the downgrading of Epsom General Hospital. Instead the audience heard a string of vague, poorly justified and, it must be said, patronising platitudes about how the PCT had our best interests at heart.

Like every other bureaucrat in Surrey's NHS, her current job is to live down the NHS's last brainwave, 'Better Healthcare, Closer To Home' (BHCH). BHCH hadn't inspired confidence. The NHS bean counters expected local people to believe that healthcare would be 'closer' if they moved the hospitals further away and seemed surprised when no-one believed the 'better' bit either.

Strangely enough, BHCH did have a point. What healthcare experts were driving at was that if local facilities, here in Bookham and its surroundings, were improved, you might not need to go to hospital. The way the medical think tank the Kings' Fund puts this is that the government wanted to 'move more care out of hospitals and into the community on the grounds of improving efficiency and access.' The problem for current soon-to-be-deservedly-ditched Health Secretary Patricia Hewitt is that by labelling it with a slipshod slogan she and her officials undermined an exercise local people might have benefitted from.

We'll never know. What we do know is that the latest wheeze in Surrey and Sussex is more of the same under a different label. 'Fit for the Future' (FFF) is an effort by the five Surrey and Sussex PCTs – Surrey, West Sussex, Brighton and Hove, Hastings and Rother, and East Sussex Downs and Weald – 'to design a new health system that will bring more care closer to people's homes', says the FFF website, 'and, at the same time, ensure the local NHS lives within its means.'

Even as a PR stunt it isn't going that well. The first FFF newsletter is nearing nine months old.

Follow the money
It won't be a great shock that a lot of this is about money. Some of it is also about medical egoes. But if you have any faith in doctors at all, you also have to weigh what they say about clinical outcomes.

Even local people who don't know a lot about healthcare feel strongly that they want hospitals to be as near as possible. Local politicians don't care whether it's right or wrong to spend healthcare resources on local hospitals. They've just leapt aboard the 'save Epsom' bandwagon as a way of punishing the government. They may be right, and if you agree with them you can sign the save Epsom petition on the prime minister's website.

But there's another side to this too. As Lockwood struggled to make clear, when you need a doctor, it isn't good enough to find any doctor. You need the right doctor. The clinicians' research appears to show that the most favourable 'outcomes' – 'results' to you and me – are determined not by how quickly patients with, say, strokes reach 'a doctor' but how quickly they reach a stroke specialist. And this means that if you have a stroke it's better to find a stroke doctor than a non-specialist, even if the stroke doctor takes longer to reach. 'That's work the clinicians have don’t,' said Lockwood, 'and it's what the clinicians tell us.'

And what that means is that journey times to hospitals are less important for the health of patients than whether they reach the right specialist. 'There are better surgical outcomes if they are seen by a specialist in a specialist centre,' says Lockwood.

Do journey times matter?
What this leaves out is that journey times do matter if you're visiting the patient, especially if you’re a near relative who lives in the same house. That's why much of the fuss about Epsom has centred around whether or not it retains an accident and emergency (A&E) department. The instinctive view of local people is that, the quicker the patient gets to hospital the better and an A&E department is equipped, first, to deal with any life-threatening problems and, second, to sort out what should happen next and where it should happen.

According to Lockwood, however, 'More than 50 per cent of the people who go to A&E at the moment, it's not necessarily the best place for them. We should be providing the right kind of care.'

If someone falls over in the street, says Lockwood, the first thing people do is call an ambulance to take them into hospital. Then, she says, they spend the next two days there trying to get out [because] they didn't need or want to be there.' They'd be better off if someone took them home and made sure they were looked after, in touch with social services and all the rest of it.

New NHS thinking, says Lockwood, is that one size doesn't fit all: 'People need a whole range of different types of care.' One of the ways the NHS has to develop is 'improving the way people are helped to look after themselves.' The Bugle can reveal that the NHS's plans for looking after ourselves go a lot further (see below).

We'll be looking after each other
Not only that, but the service has plans for us to look after each other. Lockwood told AGM attendees of the SPCT's ' ' (EPP). This consists of groups 'run by people who have a long term condition themselves for people who have a long term condition. It's about people who really know, because they are in the same position themselves,' said Lockwood.

Surrey PCT's Press office says the programme covers condition such as MS, diabetes and arthritis. The PCT is running the courses in Epsom now – at 1pm every Thursday from May 24 to June 28.

The PCT cites the example of Jean Brooks, one of 17.5 million people in the UK with an unnamed long-term health condition. Jean said the free EPP course in Epsom was 'a real inspiration', according to Surrey PCT. 'The tutors taught us how to find out more information using the internet, and also gave us lots of useful materials and publications. Each week, we set ourselves targets, and then reported back on our progress. It gave us a real sense of encouragement to achieve our individual goals,' said Mrs Brooks. 'There was a good feeling of involvement and I enjoyed being in the company of other people with chronic health problems.'

Lockwood said some of the people who have attended these courses are still meeting three years later.

Surrey says course attendees report increased confidence, an improved doctor and patient relationship, less-severe symptoms and a feeling of being more in control. But Lockwood also mentioned that belonging to an EPP group made participants less likely to call out the hospital or their GP. 'Someone may get support via a telephone service where they won’t get an answerphone. They will get understanding and advice.'

That'll really save money.

To give Lockwood credit, not only did she acknowledge concerns that 'the family has to do it all' in supporting the chronically sick, but she said 'that's not good enough.' And she added that the acute services must be available 'for people who most need it.'

'It is broke, and it must be fixed'
A telling part of her presentation was her report of anecdotal evidence from those who had gone into hospital, found that they had been well cared for and were happy with the experience. Those stories, she said, bred the idea that, 'if it's not broke, don't fix it.' For many who need urgent care, 'it is broke,' said Lockwood, 'and it does need fixing. That's why we need to do modernisation and we do need change.'

She expressed concern about the lack of availability of GPs out of hours (that's GPOOH, by the way). It's another concern being picked up in Gordon Brown's 'election' campaign. In mid-May the Sunday papers reported that Brown wants GP's surgeries to open at weekends.

Lockwood reports survey evidence that some parts of urgent care are working well and others where they aren't. 'If it's working in one area it can work in others,' she said.

Surrey is looking at its provision of walk-in centres (WICs), staffed by nurse practitioners who can prescribe antibiotics and other medicines. Surrey has WICs at Ashford, Redhill, the Royal Surrey, Weybridge and Woking. 'Is it a good model? Should we have more of them and where should they be?', Lockwood asked.

Turning to hospital provision she went for it: 'Having everybody in one place may not be a good idea. We need to have something far more streamlined.'

Lockwood spoke of 'triage', the battlefield technique for the most effective use of battlefield casualties to treat the wounded. Ambulances would be despatched to patients who were 'urgent', 'less urgent', and 'not urgent but they still need to go' to hospital. Outside those, non-urgent cases might be asked to see their GP the following day. That would make sure ambulance paramedics got to the people who needed them.

When is an UCC an A&E?
Lockwood says demand for A&E services is expected to fall as these developments take hold. Hospitals without A&E departments will instead have 'urgent care centres' (UCCs). These are able to treat 60 per cent of the people who go there, says Lockwood. She even suggested that they were, in effect, A&E departments. The rest of us are sceptical.

The UCCs would be supplemented by 'a small number of specialist A&E services where you would be at a specialist burns centre, not a local district hospital.'

The question then, she says, is 'what do we need to provide in Surrey, so one or other of our hospitals will become a centre of excellence for stroke or for cardiac [treatment]?' They will not book appointments, she said: 'We're talking about crisis treatment.'

The consultation: "Clinicians… are the ones who count"
The decisions about what goes where will be made 'when we are truly ready to do so,' after consultation. The consultations will involve 'our clinicians. They have to deliver. They are the ones whose views are important.' Then added, 'and with people who use the services'. Finally, she said, 'we have to be able to afford it. It has to be financially viable. If we have £1.3bn to spend, we can't plan something that costs £3bn.'

The deciders will be the Health Overview and Security Committee (HOSC), and the Patient and Public Involvement Forum (PPIF) will sanction the requirements.

Lockwood said no decision had yet been made about how the consultation would be carried out. If it leaflets were dropped through every door that would be 'hugely expensive' and most people would throw the information away. Using free newspapers wasn't a satisfactory alternative because their 'coverage is poor'. The decision as to which method was used would be taken after talking to patient groups.

MP asks unanswered questions
During questionsMole Valley MP Sir Paul Beresford pointed out that the consultation over the Sutton decision was 'abysmal'. This time, he said, the leaflets should go through every door. 'People don't throw it away,' he said.

Beresford also wanted to know what savings Surrey PCT was aming for in this review. And he wanted to know why only off-peak times were used to calculate travel times to hospitals.

Lockwood said the PCT would need to consider whether people do or don't read the information coming through the door and whether it was the best way to provide the information.

On finance, she said she could not answer that because it was 'not my specialism'. The consultation document would make clear the financial information 'in some considerable detail'.

Surrey PCT is talking to the ambulance service about travel times, not just 'blue light' (emergency) travel times but the PCT recognised that there's a need for people to travel who are visiting patients as well as the patients themselves. 'We’re looking at all the travel times,' she said.

One resident suggested from the floor that the last consultation the local NHS was involved in, over the future of Epsom and St Helier, showed that it 'didn't make a bit of difference' what local people think. 'You have your minds made up whatever the public say.'

Lockwood replied, 'I do hear what you are saying, and I have a huge amount of sympathy with it… A lot hasn't been done right.'

Beresford returned to the fray in Any Other Business. 'I was concerned about the presentation from the PCT,' he said. There was a lot going on that had not come out.

The Royal Surrey at Guildford is under threat, and this affects people that live in this area, he said. 'We are fighting to try and keep it and I've got the impression we are going to keep it, but we're not sure what they're going to put in it.'

On Epsom Hospital he said a bid had gone in from the owner of Denbies vineyard to run the hospital but its future was still unsure.

The problem they all faced was that, as soon as Gordon Brown took over as prime minister there would be a new secretary of state for health, and the lobbying would have to start all over again.

He didn't know why Lockwood couldn't answer his question about finance. Local MPs had met the PCT and they were going for £120m worth of cuts.

He had also asked how they were modelling travel time. Plainly, they're measuring it off-peak, he told the meeting, when on-peak is a large proportion of the day at both ends, and that's when a lot of people will be either going to hospital or visiting people in hospital – 'We're trying to get them to change it,' he said.

The consultation document will list a number of options,' said Beresford, but there will be no recommendation from the PCT on which options to choose. 'If you don't get the documents,' he added, 'I want to know.'

There's still a big fight local people had to get stuck into, said Beresford. Local people wanted both hospitals with access to them in a reasonable time.

The travel times are key. What was being tried worked in the north, where traffic and population densities were lower, 'but it doesn't work down here.'

On-line petition to the prime minister

The campaign to save Epsom General Hospital has started an on-line petition on the prime minister's website.

The petition says, 'I call on the Prime Minister to ensure that the Epsom and St Helier Hospital Trust halts the possible closure or reduction of services provided at Epsom General Hospital in Surrey. The Hospital provides high quality healthcare to the local community whose needs would be greatly damaged by such closure or reduction of provision.'
Click here if you wish to sign it.

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