HSJ live: Reaction and analysis: Lewisham to retain a 'smaller' A&E unit

5.16pm: The National Children’s Bureau has urged the government to develop a child friendly version of the NHS Constitution. It says: “Children have been denied an understanding and awareness of their rights as patients because the health service’s most important document – the NHS Constitution - is not accessible for them. “

15:00pm Another recap.

Jeremy Hunt has approved recommendation five of the trust special administrator on reconfiguring services, subject to conditions.

These are that rather than a full downgrade a “smaller A&E with 24/7 senior medical cover” be retained.

What the phrase means is not yet known and what it means for the co-dependencies in the hospital is not yet clear.

The estimates of existing A&E attendees who could use the proposed replacements goes like this:

The urgent care services proposed in the draft report: 77 per cent

The proposals in the final report submitted by the trust special administrator to Jeremy Hunt: 50 per cent.

The “smaller A&E” ordered by Mr Hunt: “up to 75 per cent”.

But important to stress again, there is no definition for the “smaller A&E”.

A copy of Sir Bruce Keogh’s advice to the secretary of state is available here.

There is no word on a judicial review, which was understood to be forthcoming from Lewisham Council if a full downgrade was approved.

One senior figure in the service described Mr Hunt’s decision as “brave” in the situation he had inherited.

Senior medics are sceptical about whether it will possible to staff a smaller unit effectively.

This difficulty has seen temporary closures of the A&Es at Queen Mary’s Hospital, Sidcup, and Central Middlesex Hospital in Brent over the past two years.

13.37pm The NHS Confederation says service must avoid “trench warfare” on reconfigurations.

Chief executive Mike Farrar said: “Changes to local health services will always create strong feelings and provoke concern.

“In many cases, the services in place are not organised to meet the needs of the local population. This can have a significant impact on the finances of NHS organisations, and risks affecting patient care.

“It is absolutely right that the recommendations for south London have been reviewed by Sir Bruce Keogh. This reinforces the point that any change must always be supported by clinical evidence.

“We need to learn the lessons from this case and others. The answer is to start discussions earlier, with doctors and leaders clearly explaining the case for change.

“Otherwise we will find ourselves perpetually in a situation of trench warfare, with staff, politicians and patients all coming out in opposition on the streets.

“Where the evidence shows that change will save lives or improve experience and outcomes for the population, we should expect political support.

“Quality needs to be the main driving force behind any change. Delivering long-term improvements requires a joined-up, whole-system solution rather than looking at one organisation in isolation.”

13.17pm Quick round up of the Lewisham situation so far.

Jeremy Hunt has approved the recommendations of the trust special administrator but with conditions over the most contentious part.

These are that Lewisham will retain an admitting “Smaller A&E” with “24/7 senior medical cover” after advice from Department of Health medical director Sir Bruce Keogh.

What exactly this means in service specification terms has not yet been revealed. Neither has the working behind the estimate that the service changes “will save 100 lives”, or over what period.

It remains to be seen whether Lewisham Council will ask for a judicial review. They had been expected to if Mr Hunt had approved the recommendations without conditions.

Sir Bruce is also leading the DH’s review of the classification of A&Es nationally and the specifications for Lewisham (if they have been worked out in detail) might represent his thinking for the rest of the country.

Mr Kershaw’s original report said 77 per cent of exisitng Lewisham A&E attendees could use the replacement urgent care centre. In Parliament Mr Hunt said the “smaller A&E” would be able to be able to treat 75 per cent of current attendees.

The DH have been in touch to point out the final report from Mr Kershaw revised his original estimate downwards to only 50 per cent, but I haven’t been able to check this yet.

13.06pm A medical director emails: “I think it’s wrong that they [Lewisham] have been dragged into the South London mess. The demerger and remerger will cause chaos clinically and financially. The case advanced by TSA is almost identical to the case for merger three years ago.”

13.01pm One senior figure in London emails: “What a terrible fudge on Lewisham’s A&E,-suspect it will be a total disaster clinically and financially.
“Very interesting that secretary of state praises work of clinicians on panels and then basically says Sir Bruce Keogh has had a look at it and come up with a different suggestion on A&E! The lives-saved stuff doesn’t hold up to scrutiny either.
“Bet you Lewisham and Queen Elizabeth hospitals limp along in debt until another TSA-style review is announced in a couple of years time.”

12.58pm Julia Manning, Chief Executive of the think tank 2020health, has responded to the decision. She said: “Everyone across South East London deserves the best possible services and Jeremy has made the right decision on all but one of Matthew’s recommendations

“On Lewisham Hospital A&E however, he is sadly delaying the inevitable and costing the taxpayer more. In an economy in which national debt continues to rise, to choose a solution that increases financial risk and debt is regrettable. It’s all very well intending the A&E to be smaller and focus on older people, but the reality is that people use their local A&E as an alternative to their GP and attendance across the country rises year on year.

“Added to this in North London commissioners are trying to close the smaller A&Es. If it remains open, people will use it as before. Unfortunately sentimentality and politics have left us with a solution that is unsustainable in the long term and will have to be revisited yet again in the future.”

12.34pm Chris Ham, Chief Executive of The King’s Fund, said of the Lewisham decision:

“South London Healthcare Trust has longstanding and serious financial problems so no change is not an option. But the decision not to accept in full the Trust Special Administrator’s recommendation in relation to Lewisham A&E and the strength of local feeling about this issue show how difficult these judgements are.

“The failure regime should be used as a last resort and must not become a back-door route for reconfiguring hospital services. With a number of other trusts also facing serious financial challenges, it is vital that, wherever possible, these problems are resolved before it becomes necessary to invoke the failure process - this will require stronger political leadership than we have seen in the past.

“When it does become clear that a hospital has reached crisis point, decisions about its future should be made as quickly as possible. However, we are concerned that the current timetable for the failure process is not long enough to properly consult local people and meet the four tests laid down by the government for significant service change.”

12.32pm Back to Lewisham. Jeremy Hunt’s announcement has baffled local MP Heidi Alexander. “Jeremy Hunt says there will be a “smaller A&E” at Lewisham. What does that mean?!” she tweets.

HSJ’s London reporter Ben Clover observes: “The slowness of various expected commentators to react suggests a lot of people expected something a bit more binary.”

12.28pm Here’s the statement on Dalton from the NHS Commissioning Board:

The NHS Commissioning Board today announces the forthcoming departure of its chief operating officer and deputy chief executive, Ian Dalton CBE. 

Ian will be moving to BT Global Services to take up the position of President of Global Health.

Ian has held a number of very senior roles within the NHS including Chief Executive of NHS North of England and chief executive of two hospital trusts, and worked on the reconstruction of civilian health services in Iraq.

Ian said:

“I am excited by my new role with BT, which will allow me to utilise my experience to work with health systems across the world. However, it has been a huge privilege to have contributed to the NHS in so many key roles over the years and to have worked with so many caring and dedicated NHS staff.

“I have been impressed by the NHS Commissioning Board’s passionate focus on the interests of patients and I am confident it will deliver real improvements for the future.   For the next period, my focus will be on delivering what I am sure will be a successful transition for the operations directorate of the NHS Commissioning Board”.

Sir David Nicholson, Chief Executive, NHS Commissioning Board said:

“I would like to take this opportunity to thank Ian for his significant contribution and dedication to the NHS over many years.  Ian has worked incredibly hard to drive forward better health outcomes for patients.   Ian will be missed and I wish Ian all the best in his new role at BT.”

12.24pm BREAKING - NHS Commissioning Board operations director Ian Dalton is jumping ship to become ‘president of global health’ at BT. More details soon.

12.20pm Ben Clover’s first full news story on the south London reconfiguration is now live. Read it here.

12.19pm Exactly which patients are taken and not taken by Lewisham’s new, smaller A&E is of wider significance. HSJ chief reporter Dave West has a story this week about a review of A&E provision across the country. The work is being done by none other than Bruce Keogh, who Jeremy Hunt revealed this morning advised him on the Lewisham decision.

Dave’s story suggests that two levels of A&E are under consideration - the top level would deal with the most urgent stroke, heart attack and neurological cases for instance, while the second level would take only less specialised cases.

12.07pm It seems like a while since we had some insight from Ben Clover. Here’s some more, fresh from Twitter:

“So this is a fudge and a slightly confusing one. JH says BK’s recommendation is that downgrade go ahead but onll with extra safeguards. These are that a ‘smaller A&E with 24/7 senior medical cover’ be retained. This will treat 75 per cent of existing attendees. That’s LESS than the 77 per cent Matthew Kershaw’s proposed urgent care centre would deal with. So what would Lewisham actually be getting?”

Ben has asked the DH for Bruce Keogh’s recommendations.

12.00pm The Foundation Trust Network has broadly welcomed the Secretary of State’s decision.

Chief executive Chris Hopson said: “South London Healthcare was a crucial test for the NHS and the Secretary of State. We must have a robust and effective way of dealing with hospitals that are no longer clinically or financially sustainable. Jeremy Hunt’s decision is the right one, not least because it is based on the clinical evidence. It is a fair and balanced assessment of what is needed for the people of South London, and shows that Mr Hunt is prepared to make difficult decisions in support of a process that safeguards patients’ interests.”

11.58am The DH has announced South London Healthcare is to be dissolved by October 2013.

Its statement, released just now, says: “The most financially challenged NHS Trust in England is to be dissolved by October 2013 to address the risk it carries for ongoing patient care and the pressure it is placing on other parts of the NHS.

“Previous attempts to solve the financial problems at South London Healthcare Trust have failed.  Currently, the trust is losing more than £1 million every week and by the end of this year, is expected to have an accumulated debt of more than £200m – money that is being taken away from patients elsewhere.

“It was on the advice of NHS Medical Director Professor Bruce Keogh that Mr Hunt also announced that he has decided that it is in the best interests of patients that Lewisham Hospital should retain its A&E.

“The Trust Special Administrator was appointed in July last year to recommend a lasting clinical and financial solution for South London Healthcare NHS Trust.  After careful consideration the Secretary of State has accepted the broad recommendations of the report, which are:

• The trust will be dissolved, with each of its hospitals taken over by a neighbouring hospital trust.  These mergers are subject to approval from the relevant regulators.
• All three hospitals within South London Healthcare NHS Trust – Queen Elizabeth Hospital in Woolwich, Queen Mary’s in Sidcup and the Princess Royal in Bromley – will be required to make the full £74.9 million of efficiencies identified by the Trust Special Administrator.
• All vacant or poorly utilised premises will be vacated, and sold where possible.
• The Department will pay for the excess costs of the PFI buildings at the Queen Elizabeth and Princess Royal Hospitals and write off the accumulated debt of the Trust so that the new organisations are not saddled with historic debts.  It will also negotiate an appropriate level of transitional funding to cover implementation.

“With regard to the proposed service changes within the new merged Lewisham-Greenwich provider, the Secretary of State asked Professor Sir Bruce Keogh, Medical Director of the NHS, to consider if they would improve patient care.

“On the basis of Sir Bruce’s advice, the Secretary of State has accepted the recommendation to centralise very specialist emergency care at four sites in South East London because this will significantly improve the quality of care and save the lives of up to 100 patients a year.

“The Secretary of State understood the financial rationale for downgrading Lewisham A&E, but in the interests of local patients has imposed some additional clinical safeguards proposed by Sir Bruce.  Lewisham Hospital will retain its ability to admit patients with less serious conditions, and will continue to have 24/7 senior medical emergency cover, allowing it to remain open as a working A&E department treating up to 75% of the patients who currently use it.

“Patients with much more serious conditions or higher risk pregnancies will be taken to Kings, Queen Elizabeth, Bromley or St Thomas’ because they are more likely to have a better result. To get to this higher standard of care, patients across South East London will only spend on average 2 more minutes in an ambulance to access specialist emergency services and on average 2-3 minutes in a private car or public transport to access consultant led maternity services.

“With these additional safeguards in place, the Secretary of State has agreed that the Trust Special Administrator should proceed to implementation, with South London Healthcare NHS Trust expected to be dissolved between June and October 2013.”

11.53am Responding to the decision, shadow health secretary Andy Burnham said there is now “utter confusion” on reconfiguration across England.

11.50am Ben Clover: “This sounds like a fudge. JH accepts Rec 5 [the downgrade of Lewisham A&E] subject to the BK amendment, the detail of which is not entirely clear. JH admits will cost more”

11.46am It seems Bruce Keogh has recommended Lewisham retains a smaller emergency unit, which deals with about 75 per cent of the traffic it currently takes.

Ben Clover: “Significant. JH: BK recommended Lewisham retain “a smaller A&E with 24/7 senior medical cover”

11.44am Ben Clover: “Was there a case that Lewisham’s care would improve? JH asked BK, BK agreed that adopting this standards could not be achieved w/ current no”

“JH: No evidence that patients were at risk from increased journey times #lewisham”

“JH: BK concluded there was no increased risk to patients on A&E #lewisham”

11.41am Jeremy Hunt says he asked NHS medical director Bruce Keogh to look at the south London reconfiguration.

11.40am Ben Clover tweets:

“JH: I respect and recognise the sense of unfairness people feel, however…”

11.39am Ben Clover tweets:

“JH: I support his analysis that a wider south London solution is the only way”

“JH: He’s not said he accepts the downgrade yet…”

11.36am Jeremy Hunt is on his feet in the House of Commons. Announcement imminent.

11.32am The news vacuum on south London is being filled with speculation about the annoucement. Paul Waugh, editor of the Politics Home website, tweets: “Would Jeremy Hunt make an ‘oral’ Commons statement rather than a Written statement if he didn’t have a glimmer of good news? #justaskin”

11.18am Also on HSJ today is editor Alastair McLellan’s leader: CCGs’ financial fears resurface. “As the leaders of clinical commissioning groups begin to put their plans into action, a significant number will be nervously wondering what dormant horror lies waiting in their area’s financial foundations,” he writes. Not one for the faint hearted, this. You’ll see what we mean if you click through.

11.15am The pro-Lewisham campaign has produced a song. You can listen to it on Youtube here, if you want to while away the minutes as we wait for the secretary of state’s decision.

11.08am @BenClover tweets: Leader of the House Andrew Lansley fielding questions in his new role at the moment. It was, of course, [Lansley] that instigated failure regime.”

10.53am Deputy Prime Minister Nick Clegg has told an LBC phone-in that the Lewisham decision is “incredibly difficult… I don’t know what Jeremy Hunt will decide.”

However, he adds. “The problem comes back to the appalling PFI contract that the previous government signed with a neighbouring health trust.”

HSJ readers will be aware that is not really true - PFI actually only accounts for about a third of the deficit at South London Healthcare.

10.46am Here’s Bill Morgan’s blog on Jeremy Hunt’s Lewisham decision. The former special advisor to Andrew Lansley writes: “Jeremy Hunt’s decision, then, is this: does he take the harder political decision now over SLHT to make it easier to take other such decisions in the future?” Mr Morgan dismisses the argument that the south London decision is a harbinger of market forces being unleashed on the NHS by last year’s Health and Social Care act is “not just incorrect – it is the opposite of the truth.” Possibly a swipe at Andy Burnham’s point from last week (see 10.39am).

10.39am Opposition leader Ed Miliband went on ITV’s breakfast programme Daybreak this morning to call for Lewisham’s accident and emergency unit to be kept. Proposals to downgrade it are based on the “wrong priorities”, he said, arguing that reconfigurations should be based on “clinical judgements, not cost judgements”.

Last week Andy Burnham said the Lewisham recommendations were “a nonsense”. “That’s a market and finance running hospital reconfiguration, and it cannot be done like that,” he said.

10.32am Wondering why there’s no update on the Lewisham decision? It’s been put back to 11.30am, HSJ understands.

10.24am NHS medical director Bruce Keogh, deputy chief executive David Flory and Monitor chair and chief executive David Bennett have written to NHS leaders to explain changes to the reporting of quality accounts. The amendments kick in from February this year.

The changes “take into account changes to the care system from April 2013, following the introduction of the Health and Social Care Act 2012, and change what information trusts are required to report in future Quality Accounts.”

Independent sector providers are also encouraged to consider including these quality indicators in their accounts.

The Mandate from the Department of Health to the NHS Commissioning Board requires the NHS to measure and publish outcome data for all major services by 2015. The data should be broken down by local clinical commissioning groups where patient numbers are adequate, as well as by those teams and organisations providing care.

“The changes we are making to the reporting requirements for quality accounts, as well as any future changes we make, will support the Mandate commitment,” the letter says.

10.10am Deputy chief executive of the NHS David Flory has written to NHS trusts and foundation trusts to inform them that, in future, a trust’s criminal liability will transfer to its successor if it merges with or gets taken over by another trust.

This is because a local fire service was thwarted in its attempt to prosecute an NHS trust following a fire at a hospital in October 2011. Between the incident and the attempt at prosecution the trust merged with another, and criminal liability did not transfer.

“Having had this brought to the attention of the Department of Health, steps have now been taken to ensure this situation cannot arise with any future mergers/acquisitions,” Mr Flory writes. It applies to all health and safety liabilities, not just ones involving fires.

9.57am There are lots of reconfigurations going on in the NHS - so why so much interest in south east London? “The process is seen as iconic in the NHS,” writes Ben Clover. “It is the first use of the [2006 Health Act] to address a trust with a monster deficit but is also seen as a test of the government’s willingness, if any, to back unpopular service reconfigurations.”

9.49am It’s official - health secretary Jeremy Hunt will announce his decision on Lewisham in Parliament at 10.30am today. Here’s the order of business for today.

9.46am The south east London reconfiguration could see the downgrade of maternity and accident and emergency servcies at Lewisham Hospital. To get you in the mood for today’s decision, here’s Ben Clover’s recent analysis of that issue.

9.36am The secretary of state’s decision on the south east London acute reconfiguration is due at 10.30 this morning. Follow @benclover on Twitter for regular updates and insight.

7.30am As the final report from the Francis inquiry nears, the question of safety of our healthcare system gains momentum. A new research by the Health Foundation draws parallels between the healthcare sector and the safety-critical industries, exploring the potential benefits of applying the safety case approach to the clinical system. Read the entire article here.