Analysed: The future of acute services in east Berkshire

The issue

Acute services in east Berkshire are considered clinically and economically unsustainable in their current form.

The difficulties in the local health economy are most clearly visible in the fortunes of Heatherwood and Wexham Park Foundation Trust. The trust has a long history of financial and performance difficulties and, as HSJ’s last briefing on this health economy more than a year ago found, is receiving ongoing bailouts from the Department of Health.

As Berkshire gets a relatively low level of funding per head of population, the financial pressures seen across the NHS in England are arguably more acutely felt in this part of the country than elsewhere. Within Berkshire, Heatherwood and Wexham Park is at the sharp end of this because its catchment area is dominated by Slough, whose population is relatively poor, and is thought to be especially demanding of acute services because typically it does not engage well with primary or preventative care.

Service changes are in the process of being implemented. Before it was dissolved, the last major act of the Berkshire primary care trust cluster was to sign off the local Shaping the Future reconfiguration proposals. It did so with the backing of local trusts and the clinical commissioning groups, then in shadow form.

Shaping the Future would bring changes to provision at Heatherwood Hospital.

Meanwhile nearby Frimley Park Foundation Trust, which is in Surrey but takes patients from the southern half of Berkshire, is in negotiations to take over Heatherwood and Wexham Park.

The main players

There are three clinical commissioning groups in the area previously covered by Berkshire East Primary Care Trust. These are: Slough Clinical Commissioning Group, Bracknell and Ascot CCG, and Windsor and Maidenhead CCG. The split reflects the three unitary local authorities in the area: Slough; the Royal Borough of Windsor and Maidenhead; and Bracknell Forest.

Although focused on very different populations, the three CCGs are cooperating closely on Shaping the Future and have a shared interest in the long-term viability of services provided by Heatherwood and Wexham Park.

Heatherwood and Wexham Park runs Wexham Park, a district general hospital on the outskirts of Slough, and Heatherwood Hospital in Ascot. That means the bulk of its work comes from Slough, but it also provides services to the more affluent Ascot and Bracknell populations.

The trust has a turnover of £232m, making it small for a non-specialist acute trust, particularly so for one split across two sites.

Heatherwood and Wexham Park has the worst possible Monitor risk ratings for both finance and governance. It is predicting a £4.8m deficit this year, although there are already concerns that it will overshoot by as much as £800,000. In May alone its deficit totalled £1.04m, nearly £300,000 over plan.

In 2012-13 it hit its target deficit of £6.9m but only after releasing all of its £3.7m contingency fund.

Frimley Park has a turnover of £265m. Although small, it is yet to experience serious financial difficulties. Its catchment area straddles relatively well-off parts of Surrey, Berkshire and Hampshire.

It has a Monitor financial risk rating of four, the second best score that can be given, and is currently predicting surpluses of more than £2m for each of the next three years.

The trust has identified several risks for 2013-14, including whether or not commissioners will accept local service changes related to the planned takeover of Heatherwood and Wexham Park.

An entry from Frimley Park’s April board papers gives some insight into why the two trusts have such different fortunes. The trust requested that Berkshire CCGs change their use of the non elective marginal rate, through which trusts are paid 30 per cent of tariff for emergency work over a set activity threshold. The trust noted that they were paid the reduced rate for only 10 per cent of the emergency patients they treated from Hampshire and Surrey. However the marginal rate was applied to a third of Berkshire patients − suggesting that serving that area was less financially rewarding than neighbouring counties. Given that Berkshire patients account for the vast majority of those seen by Heatherwood and Wexham Park, it is not surprising that the latter trust has such entrenched financial problems.

A&E under strain

While Frimley Park’s performance on accident and emergency dipped, along with the rest of the country, towards the end of the last financial year, it still hit the four-hour standard for quarter four of 2012-13 as a whole.

Heatherwood and Wexham Park’s challenges in this area were of another order, with the spike in demand affecting services that were already over-used by the local population. It hasn’t hit the target for 95 per cent of patients to be admitted or discharged within four hours since September 2012.

In addition, the trust said A&E strain was exacerbated by the closure of an emergency unit in Wycombe last year, as part of another reconfiguration programme called Better Healthcare in Buckinghamshire.

Wexham Park hospital was forced to open two “modular” wards last winter to accommodate surging emergency demand. Although they are only funded for eight months, there is a possibility that they will need to be kept open all year.

The trust has commissioned a review of acute hospital capacity in the wake of its slump in accident and emergency performance.

An independent report published by the east Berkshire CCGs identified a “vacuum” between GP services and care for life threatening situations. For many patients A&E fills that gap.

The study focused on why east Berkshire residents − those from Slough in particular − attend accident and emergency departments. It found that nearly three quarters of people who have been to A&E in the last year had made no attempt to contact their GP first.

In March only 80.3 per cent of Wexham Park A&E patients were admitted or discharged in four hours or less. The performance for the quarter was 84.4 per cent.

The trust has remained below target even as the spring 2013 pressures eased. In April, performance stood at 82.6 per cent, improving to 91.9 per cent in May – still significantly below the 95 per cent standard.

The A&E pressures also resulted in a dip in elective performance, as resources were diverted to the patients in most urgent need. As a result, Heatherwood and Wexham Park fell short on the 18 week referral to treatment target for 90 per cent of admitted patients across all specialisms. Meanwhile, rate of cancelled operations was 50 per cent higher than planned. The trust has brought in external consultants to support a review of how efficient its use of operating theatres is.

Stroke care has also suffered in recent months, with capacity again cited as the main reason.

The target for 95 per cent of patients to be admitted to an acute or hyper acute stroke unit within four hours of arrival was not met in 2012-13. Performance hit a low of 17 per cent in February.

Implementing Shaping the Future

Implementing Shaping the Future would mean Heatherwood Hospital would permanently lose three services: a birthing centre already temporarily closed due to safety concerns; a stroke rehabilitation ward; and a minor injuries unit, which would be replaced by an urgent care centre a couple of miles away in Bracknell.

Heatherwood and Wexham Park now has a clear plan for Heatherwood – to rebuild it as an elective surgery hospital. This has been costed at around £40m-£45m. Although the plan is to fund this largely through the sale of some land on the hospital site, it is not yet clear whether that will be enough on its own or if extra capital will need to be found from elsewhere.

The reconfiguration is under way. The Ascot Birthing Centre will never reopen. The Heatherwood rehab unit is on course to close at the end of the year, with alternative services already being put in place.

The minor injuries unit is also supposed to close in December, but that part of the plan has hit a snag – the Royal Borough of Windsor and Maidenhead is applying for a judicial review to get the decision overturned.

The judicial review

The reason for this, bluntly, is because the existing minor injuries unit at Heatherwood is in the Royal Borough of Windsor and Maidenhead, while its proposed replacement, although only 2.2 miles away, would be located over the council border in Bracknell Forest.

The decision has placed Windsor and Maidenhead at loggerheads with its neighbouring councils and with the entire health economy – although it argues that it is simply doing the right thing by its local residents by trying to keep services on their doorstep.

Local sources estimate that the review would cost NHS organisations hundreds of thousands of pounds in lawyers’ fees.

If a review were granted, and found in favour of the council, that would impact on plans to rebuild Heatherwood. If Windsor and Maidenhead gets its way, some of the facilities earmarked for elective surgery would have to be devoted to less profitable non elective work.

Whether that would affect the viability of the Heatherwood site, and whether that in turn would be enough to make Frimley Park walk away from the takeover talks depends on who you speak to. The line of Philippa Slinger, chief executive of Heatherwood and Wexham Park, has been that “it would be a shame” if it did. Andrew Morris of Frimley Park has gone further, publicly arguing that it does indeed put the Heatherwood and Wexham Park talks at risk.

However, some local sources say that keeping a minor injuries unit at Heatherwood would actually have a minimal impact, and that a lot of the resistance is merely political. Specifically, Bracknell and Ascot CCG feels it needs to deliver some new local services for the people − and GP practices − of Bracknell.

‘It would be damaging if a council showed itself able to scupper even a relatively unambitious reconfiguration by playing crude politics’

Although Shaping the Future would make a fairly minimal contribution to the long-term overall viability of Heatherwood and Wexham Park − it would not do much for emergency demand, for instance − it is important to the credibility of the local CCGs. It would be damaging if a council showed itself able to scupper even a relatively unambitious reconfiguration by playing crude politics. And, implementing Shaping the Future will be many local people’s first encounter with the CCGs. They therefore need to be able to convince local people that they are acting in the best interests of patients and are not simply forcing through a set of changes regardless of local feeling.

Mindful of the second point, the CCGs have set up a “community partnership forum” to ensure that the clinical justifications for the changes are properly communicated.

Frimley Park takeover

It is clear that even if it is fully implemented according to plan, Shaping the Future on its own is not enough to ensure the overall sustainability of acute services in east Berkshire. For that, more fundamental restructuring will be necessary.

Frimley Park has been testing whether the acquisition of Heatherwood and Wexham Park is in its best interests. Before it commits to taking on a troubled trust nearly as big as itself, it wants to be assured that its own financial position will not be compromised, for instance by projected activity levels or plans for the future of the Heatherwood site.

As things currently stand, both trusts believe a takeover is the best way to ensure the long-term sustainability of local services, and Monitor and the Department of Health have supported the proposal so far.

Frimley Park is currently waiting for assurance from the DH that Heatherwood and Wexham Park will come with a “dowry” so it won’t have to invest its own capital in bringing services and facilities up to scratch.

The Frimley Park board has made no provision for any extra costs related to the takeover and does not expect to incur any. It assumes that any extra expenses that do arise will be funded “externally”.

Numbers have not yet been agreed but the dowry is expected to be worth in the region of £20m a year − in 2012-13 the trust received a £29m bailout, this year it was reduced to about £18m. This is being used to make up for the trust’s historic under investment in things like IT, diagnostic equipment, power generators and estates.

It is hoped that future payments could pay for an upgrade to Wexham Park’s A&E unit. The existing facilities date from the 1970s, and were designed for around 70,000 patients a year. Last year it saw 117,000.

Discussions are ongoing. The Frimley Park board is optimistic that it will be able to proceed to the next stage soon: we should see the outline business case for the acquisition in August.

Local sources are clear, incidentally, that this would be takeover by Frimley Park, not a merger of equal partners.

Care quality at Heatherwood and Wexham Park

The Care Quality Commission has published a damning report on the quality of care at Wexham Park hospital.

Prior to this, there were mixed indicators. The CQC’s inpatient survey painted a very negative picture of care at Heatherwood and Wexham Park. There was also a reported problem with the number of patients being harmed through falls.

Despite this, the friends and family test reported that two thirds of patients were highly likely to recommend the trust’s services, comparing favourably with the nearby Royal Berkshire Foundation Trust, although trailing behind Buckinghamshire Healthcare Trust and Oxford University Hospitals Trust. But, it is perhaps telling that Heatherwood and Wexham Park struggled to get responses from A&E, where we now know care was suffering due to demand exceeding capacity.

The CQC report found that care was not good enough in areas such as A&E that were already widely known to be under intense pressure. What is more deeply concerning is that the investigation also found evidence of poor nursing care on the wards, with concerns around cleanliness, care planning and the security of drugs, which suggest ingrained cultural problems.

This will be a blow to chief executive Philippa Slinger in particular. Ms Slinger, a trained nurse, took over in autumn 2011 when Heatherwood and Wexham Park was failing both in terms of performance against key care standards, and financially. If, after nearly two years of work, she is judged to have underestimated the scale of the cultural problems in the trust, or failed to fix them, the CQC’s verdict could put her position in jeopardy.

The likely outcome

Shaping the Future will be implemented, although the Heatherwood minor injuries unit closure is expected to be held up because of the judicial review.

If the judicial review is granted and finds in favour of the council, it is likely that the local NHS partners will try again to close the Heatherwood minor injuries unit, even if it means consulting again.

The takeover will likely go ahead whatever happens regarding the judicial review. It would result in a single provider trust with a turnover of around £500m – placing it above the widely cited £400m-£450m long-term viability threshold. It is hoped that pooling resources could produce economies of scale worth around £8m-£9m in back office functions alone.

Services would not be widely reconfigured − no one is talking about closing a hospital site or downgrading any of the local A&Es.

However, it is expected to lead to the merging of many of the two trusts’ major specialisms. Since NHS England has made clear its intention to introduce 24/7 services, it has become clear that some specialisms provided by both trusts cannot operate in their current configuration because neither trust is big enough to employ enough clinical staff. However, between them, the trusts have enough consultants to run 24 hour cardiology services, for instance, or orthopaedics services. The trusts are thought to be close enough that the travel times for patients would not be a barrier to merging many services and running them across two sites.

The CQC report could yet put paid to the takeover plans. The quality of care at Heatherwood and Wexham Park is known to have been identified as a possible “walk away point” for Frimley Park. The board could decide to withdraw its bid because it judges Heatherwood and Wexham Park too troubled to fix. If it does, Heatherwood and Wexham Park would soon be put into administration.