Despite winter snow and a flu outbreak, a high profile trust reorganisation was pushed through in order to start addressing debt problems, low performance and poor service design. Their commitment may result in the rescuing of the trust’s goal of foundation status, as Daloni Carlisle reports.

If you were going to close an accident and emergency department on one of your trust’s three hospital sites, you probably wouldn’t choose the week before the worst snowfall of the century and a flu outbreak.

Spare a thought, then, for managers at South London Healthcare Trust who chose late November 2010 to close the A&E at Queen Mary’s Sidcup, replace it with an urgent care centre and centralise the main A&E departments on two sites at the Princess Royal Hospital near Bromley and the Queen Elizabeth Hospital in Woolwich.

A week later, as staff adjusted to new teams and patients to the new service, there was a turn in the weather, quickly followed by a flu outbreak.

To be fair, the managers were no more able to predict either disaster than the Met Office or epidemiologists. The timing was chosen, says director of emergency care Mark Cubbon, to allow the changes to settle down before the winter pressures hit hard. But ask him today what the major challenge of the service reconfiguration was and he will say without a pause: “The terrible weather. It disrupted the whole system.”

And that is perhaps the interesting point. It was not local opposition or NHS activists taking to the street to protect “their” A&E. As chief executive Dr Chris Streather says: “We managed to close the A&E without causing a riot.”

The story of how South London Healthcare Trust did this and how it is tackling debt, outdated services and poor clinical indicators while struggling towards foundation trust status may hold some lessons for other trusts up and down the country.

Highly political

The trust was created in 2009 from the merger of three smaller district general hospital-based trusts. All had heavy debts, and two – the Princess Royal and Queen Elizabeth – had private finance initiative contracts. It was caught up in the mire of a regionally led and highly political reconfiguration plan (NHS London’s A Picture of Health) and had some patient safety and satisfaction indicators bad enough to keep the chief executive and medical director awake at night.

Women were staying away in droves from its maternity services, which were beset by a chronic shortage of midwives, while in A&E the planning blight had conspired to create equally bad staffing issues.

Today, the trust management has successfully closed not just the A&E at Queen Mary’s Sidcup but also its maternity department and concentrated expertise on the remaining units to create services with a much higher rate of consultant cover.

It has begun the work to develop Queen Mary’s Sidcup into an elective centre rather than a DGH, opened a new midwifery-led maternity unit at the Princess Royal, and opened a hyper acute stroke unit.

Last year it clawed back £45m – the biggest saving in London and some 10 per cent of its budget. The vacancy rate in midwifery is down from 60 posts (out of a total of 300) to 10 – and it recently had 100 applicants for those 10 posts.

Caesarian section rates are down, and the number of serious untoward incidents in maternity now marks the hospital as the third safest in London. There was just one MRSA case last year and mortality rates have been slashed from above the national average two years ago to among the best in the country now.

Medical director Roger Smith says: “In the 12 months to the end of March 2011 we had about 400 fewer deaths than we would have expected had we been at the national average. How does that feel? That all the difficulty and pain of the last two years has been worth it.”

Talk to service managers at the trust and they will list all the factors for success that you might expect: clinical engagement; open relationships with partner organisations; a thorough community engagement strategy; tight project management; a keen eye on reporting and governance.

Mr Cubbon, for example, says: “The reconfiguration was quite complex because of the range of services that had to be moved and the range of partners involved. We were pleased we managed it in a very tight timescale, by using a project management office model that allowed us to flag up issues as they arose and respond quickly. It is a good model for delivering a significant amount of change.”

For Dr Smith the running theme is that “clinical reorganisation has to be at the heart of what we are doing. You cannot sell change on the basis of a financial argument”. The clinical case for closing the A&E and the maternity units at Queen Mary’s were strong and credible, he emphasises.

Over in maternity – where the closure of the unit at Queen Mary’s has passed off without anyone manning the barricades – clinical leadership has been important.

General manager Simon Henley-Castleden’s first change was to replace three directors of midwifery with a single chief midwife. In April 2010 he recruited Donna Ockendon, who has a track record of overseeing change.

She in turn tackled the staffing crisis first, developing what she claims is the best continuing professional development programme for midwives in London and successfully attracting high-calibre new recruits as a result.

“You have to stabilise the workforce first,” she says.

The closure of the maternity unit was not easy, she admits. “We saw it as a clinical necessity but we knew it would be difficult and made ourselves available on call 24/7,” she says. “It made us very visible and has reaped huge benefits. Midwives knew there was someone senior available at all times.”

Dr Streather has his eye on the future. The financial situation at the trust is still tricky, with a £45m deficit forecast, blamed on a drop in income. The trust is listed by the Financial Times as “financially unstable” and a PFI hotspot.

He says: “As a chief executive I have to deliver on four things. Quality and safety, performance, strategy and finance. In 2009 we were not delivering on any of these. Now we are delivering on the first three but if I am honest we have done least well on the money.

“Despite last year’s savings we remain one of the most indebted trusts. With changes in commissioning intentions, our underlying deficit is £60m.”

The big question is whether the trust can make FT status. An examination by external consultants says yes, but only just and only by reducing length of stay and increasing theatre use dramatically. Hence the strategy to create the elective and ambulatory centre at Queen Mary’s, releasing some of the estate at this non-PFI site, and create subspecialties that would allow the trust to treat more complex cases locally. 

And if this doesn’t succeed in bringing the trust into balance? “I think that there are enough FTs in London to pick up our services if we do not get there,” says Dr Streather.

“The risk to local people of that is that elements of provision will get centralised and I think this would create a service not to the benefit of local people.”