Battle lines have been drawn between the four acute trusts in Greater Manchester fighting for  ‘specialist hospital’ status in a major citywide reorganisation.

The Healthier Together public consultation, launched last month, proposed to concentrate emergency and high risk general surgery currently performed across ten hospitals onto four or five sites.

These “specialist hospitals” would have consultants based in accident and emergency for at least 16 hours a day compared with 12 hours a day in the remaining “local general hospital” sites.

While three hospitals - Manchester Royal Infirmary, Salford Royal Hospital and Royal Oldham Hospital - would be guaranteed the “specialist” status under the consultation proposals, others would lose on-site emergency surgery services.

Such a set up leaves four foundation trusts battling to secure the remaining one or two “specialist” slots: Bolton FT and Wrightington, Wigan and Leigh FT in the north west of the conurbation, and University Hospital of South Manchester FT and Stockport FT in the south.

The consultation - launched less than a year before a general election - has generated intense political heat, with even prime minister David Cameron forced to defend it last week in the local press.

But while some local MPs attacked the Healthier Together proposals and process, each of the four trusts has argued that geography or clinical interdependencies mean its hospitals must retain emergency surgery. In some areas, these arguments are primarily about access.

Stockport chief executive Ann Barnes told HSJ the trust also served rural communities in Derbyshire and Cheshire that would be unable to reach a specialist centre by ambulance within the time limits set by Healthier Together if Stockport’s main site did not retain emergency surgery.

“Travel times are significant in terms of outcomes” for emergency surgery, she said. 

“To not have Stepping Hill [Hospital] as one of the specialist sites means the good people - particularly of High Peak, but also we take in from a lot of Cheshire - would not be able to achieve the 45 minute standard that is considered the appropriate standard that Healthier Together use for access for emergency care.”

This claim is disputed by South Manchester chief executive Attila Vegh, whose trust is in competition with Stockport to be the specialist site for the “southern sector”.

Mr Vegh told HSJ access data had been debated “at length” in the southern sector by clinicians, provider chief executives and commissioners, as part of a national programme to support challenged health economies.

He said: “The conclusion was that the difference between the access and travel time for Stockport and UHSM is marginal, and that’s not big enough to make any decisions about whether UHSM or Stockport should be the specialist or the major emergency site.”

South Manchester believes its existing portfolio of specialist services - including cardiac and thoracic surgery, vascular surgery, burns and plastics - should have seen it awarded a guaranteed “specialist hospital” status.

Dr Vegh said these services were “absolutely mission critical for being a major emergency site with 24-7 acute surgery support”.

He said: “I believe, I hope that by the end of the consultation process [these] will be recognised as critical interdependencies that would justify UHSM, not only to be a specialist site, but being a fixed point for major emergency services.”

This claim is disputed by others involved in the Healthier Together review.

Manchester

Each of the Manchester trusts have argued that their hospitals must retain emergency surgery

Nick Lees, a consultant general surgeon at Salford and one of Healthier Together’s clinical spokesman, told HSJ: “Plastics isn’t uniquely at [UHSM’s] Wythenshawe [Hospital]. Thoracics isn’t uniquely at Wythenshawe either. What’s more, the need for general surgery to support those services in an emergency in an emergency is not clear.

“There are standalone cardiothoracic hospitals up and down the country that don’t have emergency general surgery on site, for example.”

In the north west of the conurbation, Bolton chief executive Jackie Bene based her argument for specialist status on figures showing the trust has the second busiest A&E in Greater Manchester.

This made it busier “by a long chalk” than its neighbours in Salford and Wigan.

She said that - due primarily to accessibility - Royal Bolton took 93 per cent of local non-elective patients, compared to 13 per cent taken by Wrightington and 9 per cent by Salford.

Only 0.5 per cent of Bolton patients went to Wrightington’s A&E, and 1 per cent went to Salford, Dr Bene added.

“We’re therefore busy already for emergency surgery and require… on-site emergency surgical presence to deal with the volumes of patients we see,” she said.

Against this, Wrightington chief executive Andrew Foster argued that Wigan’s population was the largest in Greater Manchester - at 318,000 people - and the furthest from the centre.

“We are the trauma unit for this part of the north western sector because of our geography, because we’re the furthest out,” he said.

“We think the logic that [makes us] the centre for trauma would be the same logic that would apply for emergency surgery.”

The trust’s case for specialist status will also emphasise its performance on quality and outcomes measures, performance targets, the friends and family test, and finance.

Unlike some other contenders for specialist status, it had good financial risk ratings, and had “capital and cash available” to invest in implementing Healthier Together, Mr Foster added.

While South Manchester has privately briefed MPs against the Healthier Together consultation, Mr Foster is the only provider chief executive to make his criticisms public. His tweets have criticised the consultation process and its proposals since it began.

He told HSJ he was concerned the designation of hospitals as “specialist” or “local” - as “one type is a winner, the other type is a loser” - would pre-determine future decisions about the reconfiguration of other services.

The Healthier Together consultation argued that local and specialist hospitals will work together in sectors to provide “single services” for general surgery.

Under its proposals, consultant general surgeons would be employed to work across more than one hospital, performing emergency and high risk work at specialist sites and elective work and clinics at local sites.

Mr Foster said: “My concern is as your mission creep grows, as the number of services in scope grows, what’s covered by the single service eventually becomes such a large portion of your organisation that you no longer effectively have separate organisations. So the logical conclusion of the mission creep is you end up with organisational takeover and merger.”

Dr Vegh and Ms Barnes said the designation of sites as local hospitals could affect trusts’ ability to recruit and retain talented staff.

Ms Barnes said: “The reality is once a hospital becomes designated as specialist or local, other services which are not directly part of Healthier Together such as orthopaedics, urology… children’s services all start being affected because I believe the very best of staff will be interested in working at the specialist hospitals.

“I know the single service is meant to sort that out, but it’s a yet to be tested model.”

However, Mr Lees said Greater Manchester “already struggles to recruit to lots of posts precisely because we have small catchment populations”.

“Good doctors don’t necessarily want to go to hospitals that don’t do very much of the thing they’re interested in,” he said.

“We’re hanging on by a thread, frankly, in Manchester’s hospitals, because we can’t recruit people, because people don’t want to come and work in hospitals with small catchments to do procedures infrequently on rotas that are dependent on one or two people.”

Mr Lees added that consultant general surgeons would be recruited by a sector of hospitals, not individual trusts, and that conversely, some surgeons in the latter stages of their careers might prefer to spend more time working in local hospitals than doing nights and weekends at the specialist centre.

“This notion that you can’t recruit to a general hospital is flawed.”