Essential insight into England’s biggest health economy, by Ben Clover

Re-grasping the nettle

Most of London’s sustainability and transformation plans are now out or have produced some kind of draft.

Most radical of the five is north west London – which boldly/unwisely talks of reducing the bed base by 500.

People who know these things have long said that the sector is over-bedded. It is the patch about which a senior manager once said you “couldn’t throw a stick without hitting an A&E”. But with hospitals running this hot it is understandably hard to explain where these beds should disappear from.

South west London’s STP has also been bold, saying the number of accident and emergency units in the area needs to be reduced from five to maybe three.

This is not the first time this has been said. All corners of London have clunkily named, usually unsuccessful, projects to close A&Es in their past.

The last one in south west London was called “Better Services, Better Value” and was a bold attempt to downgrade one or both of the units run by Epsom and St Helier University Hospitals Trust.

Bold because of its ambition, and bold because in the days of coalition government it touched the patches of two Lib Dem MPs, including health minister Paul Burstow, whose decision to oppose the plans his government supported did not save him at the 2015 election. It would also have affected then justice minister Chris Grayling’s seat. Plus Epsom is very definitely in Surrey, whereas St Helier is (just) in London, so it wasn’t really up to the old London strategic health authority which was pushing the plans, and the programme died a lonely death.

Now an A&E downgrade plan is back, and this time the man who successfully downgraded A&Es in north west in NWL – Daniel Elkeles – is chief exec of Epsom and St Helier.

And the logic of the patch hasn’t really changed. St George’s is a trauma centre, so its A&E isn’t going anywhere. Croydon has long been troubled but sits at the middle of a large, ill population. They tried to close Kingston about eight years ago but it’s in a Conservative-held marginal constituency. That only leaves Epsom and St Helier.

The trust has long failed to get the money to do a compromise-rebuild of the trust as one hospital and it seems unlikely to get it now, in the post-capital NHS.

South east London already tried and failed to downgrade an A&E, in the wake of the dissolution of South London Healthcare Trust. (Forgotten fact: as the London SHA ran into more and more issues with its SWL plan, the idea of putting Epsom and St Helier in the failure regime was mooted, and was blatantly about reconfiguration rather than failure.)

North central London’s STP document has some interesting facts in it but seems to have ducked saying anything contentious.

It points out some fairly stark disparities in senior cover across its trusts but doesn’t make recommendations about what should be done about it.

One interesting snippet on mental health: “Camden and Islington have amongst the smallest community mental health services per person in England. Community teams reduce the number of people with a mental illness ending up in hospital.”

Camden and Islington Foundation Trust had a cluster of deaths over 2013 and 2014 that were investigated to see whether there was a connection to its closure programme for mental health inpatient beds (it wasn’t proved but it wasn’t disproved; they’ve re-opened beds since).

But you’re not supposed to be closing beds at all until you’ve got your community mental health services beefed up – it’s odd therefore that we’re now hearing that Camden and Islington’s community services are very small.

Also, what can explain this? “In recent years there has been a big increase in the numbers of people receiving a first diagnosis of a serious mental health condition in A&E, and around 38 per cent of people admitted to inpatient hospital wards in Camden and Islington are new to mental health services.

“These issues are partly related to the large number of people moving in and out of NCL, with significant differences between daytime and night time populations” – yes, but the large number of people moving in and out of Camden and Islington is hardly a new thing – so why the recent increase? Has access to primary care got worse? Shouldn’t IAPT services have seen some of these people beforehand? Are the police referring more people? (sidenote, there is no “high quality health-based place of safety in NCL”, the case for change says)

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Which just leaves north east London, the STP for which had not been made public at the time of writing.

Multiple, multiply challenged acute providers, some very sketchy primary care and long paused plans to downgrade King George Hospital in Ilford.

The degree of nettle re-grasping or otherwise in their STP will be interesting to see.

London Eye features a look at what’s going on in England’s biggest health economy. London has the best and worst regarded hospital trusts in the country. It has excellence and dysfunction in commissioning and primary care. I will cover all of this.

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