reconfiguring hospital services in shropshire

8/7/2019 Reconfiguring Hospital Services in Shropshire

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Reconfiguring Hospital services in Shropshire.

Keeping it in the County Dec. 2010.

Response prepared by D. Sandbach.

The argument for rational configuration and long term sustainability.

Rational Configuration.

The policy of maintaining two main hospital sites in Shropshire at RSH and PRH is in my opinion the

least rational option available to the people of Shropshire, mid Wales and the local NHS TrustBoards.

The consultation document, under option 3 and 4, makes it perfectly clear that:

A) A single DGH is the best option see option 3 page 10.

B) The second best option is option 4 all major inpatient and emergency activity occurring on

one site.

Both these options are dismissed in the consultation document due to the current financial climate.

I believe dismissing these two rational options is not in the best long term interest of health care in

Shropshire.

I am sure that setting a single site hospital as a strategic goal and delivering this goal over a period of

years is the right thing to do and is possible even though the UKs current economic climate is not as

good as it has been in the recent past.

The consultation document states:

In many ways, this would be an ideal solution. We would be able to design new facilities from

scratch. We would have the most up-to-date equipment in purpose-built accommodation.

We would also have all our staff and services together on one site, which would make it easier for us to usethem where they are needed most at any time.

1

SaTH and the PCTs were formally notified that the idea of a single site was technically and financially

viable in September 2009:

Recommendation 3: To NOTE that all three options for the 2020 single site have the potential to be

technically and financially feasible2

1Source Keeping it in the County page 10.

2Source Agenda Item 4. 22 September 2009 T&W PCT Board meeting.


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The consultation document fails to give a comprehensive reason as to why a single site DGH in

Shropshire is a sound idea. An idea that is supported by local clinical personnel and by external

clinical advisors.3

By avoiding this issue the public are kept in the dark about the wider health care

benefits of such a strategic policy.

Sustainability.

The financial climate in the UK is not as good as it has been in the past. The need to deliver

effective stewardship of scarce public resources is vital to keeping hospital services in the

County.

Demographic change will continue to place ever greater pressure on financial allocations.

Pressure to deliver clinical improvements and improved labour productivity in the NHS will

increase.

Pressure to have increased medical specialisation will continue.

The potential for the private and voluntary sector to increase their involvement in treating

publically funded patients will put pressure on SaTH to rationalise services in order to

compete and provide a modern 21st century service for the public.

Given the factors noted above I have concluded that a two site hospital system in Shropshire is not

a sustainable clinical or financial proposition in the medium to long term.

If we can all agree that a programme of centralising services on one site is in all our interests

(clinical, public health and political) then we can rest assured that our hospital service in Shropshire

is in a strong position to weather the up coming changes in the way health services are delivered in

this country.

The case for one DGH.

Option 3 Page 10 Keeping it in the County-

In many ways, this would be an ideal solution. We would be able to design new facilities from

scratch. We would have the most up-to-date equipment in purpose-built accommodation.

We would also have all our staff and services together on one site, which would make it easier for us

to use them where they are needed mostat any time.

In order to provide some context to this statement I have prepared, using published Annual Reports

for 2009/10, a high level analysis of SaTHs performance i.e. a two site hospital service compared

with two centralised acute hospital services.

The assessment compares similar but not identical organisations.

3

National Clinical Advice Team received in January 2009Sourcehttp://www.sath.nhs.uk/Library/Documents/ournhs/090917-NCAT%20Final%20Report.pdf
http://www.sath.nhs.uk/Library/Documents/ournhs/090917-NCAT%20Final%20Report.pdfhttp://www.sath.nhs.uk/Library/Documents/ournhs/090917-NCAT%20Final%20Report.pdfhttp://www.sath.nhs.uk/Library/Documents/ournhs/090917-NCAT%20Final%20Report.pdfhttp://www.sath.nhs.uk/Library/Documents/ournhs/090917-NCAT%20Final%20Report.pdf


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The assessment is broad brush approach but taken as a whole confirms what is only common sense

i.e. that to run two hospitals doing more or less the same core activity on each site is more

expensive and less clinically efficient than running one hospital.

Please note the assessment in no way implies that the staff of SaTH are not doing their very best to

deliver good clinically sound hospital services for the benefit of their patients, they are where theyare working in an inefficient two site system.

The table on the next page is a comparison between three Acute Hospital Trusts:

Shrewsbury and Telford Hospitals NHS Trust (SaTH)

The Countess of Chester Foundation Trust (CoCH)

Royal Wolverhampton Hospitals NHS Trust (RWH).

All three organisations are in the same service area i.e. the provision of District General Hospitalservices. There are some differences e.g. RWH is a designated Regional Heart and Lung centre. The

catchment area for RWH is 330,000 the catchment area for CoCH is 250,000 where as the catchment

area for SaTH is 500,000.


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Performance analysis of one split site DGH SaTH and two single site DGHs CoCH / RWH.

Comparator SaTH CoCH RWH Comment

Income from

Treating

Patients

242,156,000 158,148,000 264,077,000

Income from patient care activity at RWH is 9%

higher than SaTH

Activity

508,547 427,000 750,000

SaTH produces 32% less service than RWH. If

SaTH were on one site the public could expect

an activity rate of 675,000p.a.

Beds

890 600 706

SaTH has the highest number of beds. As a

single site organisation SaTH could reduce its

bed compliment.

Staff

4201 3000 5000

Calculations prepared for SaTH show that it has

around 120 too many beds this is because the

beds are on two sites.

Average cost

per item of

activity

476 370 352

The average price of service activity from SaTH

is around 28- 34% more than the CoCH and

RWH.

Ratio of staff to

activity 1 : 121 1 : 142 1 : 150

SaTH labour productivity is 18% below that of

the CoCH and 19% of the RWH. This is becausethey are not concentrated on one site.

Ratio of staff

per bed 4.72 : 1 5 : 1 7 : 1

SaTH has the worst staff to bed ratio, 5.6% less

than CoCH and 33% less than RWH.

Activity per bed

ratio 571 : 1 711 : 1 1062 : 1

SaTH has the worst utilisation ratio by at least

20%.

Ratio of

catchment pop.

to beds

561.79 : 1 416.6 : 1 467.2

SaTH has the highest ratio of beds per

population 34% more than CoCH 20% more

than RWH

Ratio activity to

catchment pop. 1.017 : 1 1.70 : 1 2.27

People in the SaTH catchment often get their

hospital services out of county the cross

border leakage is around 10% or from

providers other than SaTH in Shropshire.


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The figures above clearly show what is instinctively obvious i.e. that the operation of a twin site

acute hospital services is not in the best interest of people living in the SaTH catchment area because

having two hospitals in the county doing similar work is:

clinically is inefficient

expensive and wasteful of resource

an impediment to delivering more and better health care.

The difference in the unit cost of service provision shows how much more expensive a dual site

service is; this is very important since it translates into money being spent on fixed and semi variable

over heads rather than staff, clinical quality and increased over all service productivity / delivery

levels.

Translated into activity terms these figures suggest that a single hospital site in Shropshire could

provide the population with between 67.8 and82.3 million pounds worth of extra health care (28- 34% of 242,156,000) this translates into 183,000-231,830 extra health service contacts in the

acute hospital service or some extra resources for other health related activity e.g. community and

mental health care.

Put another way, the pay and non pay cost of the community service in Shropshire e.g. Community

hospitals, community nursing etc is around 38 million per annum4. If the Acute hospital service was

centralised Shropshire as a community could afford to have more community based beds and

community based, in home, services provided by community doctors, nurses and therapists caring

for people in or close to their home.

Capital Funding to support change.

In the near future SaTH will become a Foundation Trust in its own right or become part of an existing

Foundation Trust. Access to capital for developing services will become simpler because Foundation

Trusts are not subject to Delegated Limits for Capital Investment:

NHS Foundation Trusts are not subject to delegated limits for capital investment set by the

Department of Health.

5

4Source

http://www.shropshire.nhs.uk/Documents/docs_common/Publications/Board%20Papers/2011/25%20January

%202011/9.1%20Board%20Report%20-%20Financial%20Performance%20-%20combined.pdf

5Source

http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_080865.pdf
http://www.shropshire.nhs.uk/Documents/docs_common/Publications/Board%20Papers/2011/25%20January%202011/9.1%20Board%20Report%20-%20Financial%20Performance%20-%20combined.pdfhttp://www.shropshire.nhs.uk/Documents/docs_common/Publications/Board%20Papers/2011/25%20January%202011/9.1%20Board%20Report%20-%20Financial%20Performance%20-%20combined.pdfhttp://www.shropshire.nhs.uk/Documents/docs_common/Publications/Board%20Papers/2011/25%20January%202011/9.1%20Board%20Report%20-%20Financial%20Performance%20-%20combined.pdfhttp://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_080865.pdfhttp://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_080865.pdfhttp://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_080865.pdfhttp://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_080865.pdfhttp://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_080865.pdfhttp://www.shropshire.nhs.uk/Documents/docs_common/Publications/Board%20Papers/2011/25%20January%202011/9.1%20Board%20Report%20-%20Financial%20Performance%20-%20combined.pdfhttp://www.shropshire.nhs.uk/Documents/docs_common/Publications/Board%20Papers/2011/25%20January%202011/9.1%20Board%20Report%20-%20Financial%20Performance%20-%20combined.pdf


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Having spoken to Mr. J. Mann from the Department of Healths Capital Investment Branch I

understand that a Foundation Trust can access capital as long as the project can be afforded, FTs

have the autonomy to proceed with capital projects.

The statement in the consultation document In the financial climate now facing the nation, that

money (350450 million) is not available is a defeatist and very pessimistic position given:

a) A Foundation Trust access to private capital is a possibility.

b) The Government is committed to capital spending remaining higher in real terms than ithas been on average over the last three Spending Review periods.

6

I believe that we should aspire to a single site DGH in Shropshire and I think the public should be

asked to give their views on the following three models of care:

Model 1.

As proposed in the consultation document.

Possibly with Women and Childrens services

staying at RSH and surgery transferring to PRH

from RSH. NB the 60 million price tag quoted in

the consultation document for relocating the

Women and Childrens service at RSH is OTT7/

8.

Model 2.Concentrate all major inpatient and emergency

activity on one hospital site and deal with

planned activity at the other.

If executed over a period of several years this isan achievable goal.

Model 3.

Provide one DGH for the county at RSH / PRH or

new build between the two existing sites.

Best option needing vision and perseverance to

achieve.

6Source HMG Treasury Departmental settlements:http://cdn.hm-treasury.gov.uk/sr2010_chapter2.pdf

7Sourcehttp://www.pat.nhs.uk/uploads/20100603_231%20New%2032m%20w&C%20building%20complete

%20DRAFT1.pdf8Sourcehttp://www.pat.nhs.uk/uploads/20101021_A3%20NMGH%20generic%20poster%20new.pdf
http://cdn.hm-treasury.gov.uk/sr2010_chapter2.pdfhttp://cdn.hm-treasury.gov.uk/sr2010_chapter2.pdfhttp://cdn.hm-treasury.gov.uk/sr2010_chapter2.pdfhttp://www.pat.nhs.uk/uploads/20100603_231%20New%20%C2%A332m%20w&C%20building%20complete%20DRAFT1.pdfhttp://www.pat.nhs.uk/uploads/20100603_231%20New%20%C2%A332m%20w&C%20building%20complete%20DRAFT1.pdfhttp://www.pat.nhs.uk/uploads/20100603_231%20New%20%C2%A332m%20w&C%20building%20complete%20DRAFT1.pdfhttp://www.pat.nhs.uk/uploads/20100603_231%20New%20%C2%A332m%20w&C%20building%20complete%20DRAFT1.pdfhttp://www.pat.nhs.uk/uploads/20101021_A3%20NMGH%20generic%20poster%20new.pdfhttp://www.pat.nhs.uk/uploads/20101021_A3%20NMGH%20generic%20poster%20new.pdfhttp://www.pat.nhs.uk/uploads/20101021_A3%20NMGH%20generic%20poster%20new.pdfhttp://www.pat.nhs.uk/uploads/20101021_A3%20NMGH%20generic%20poster%20new.pdfhttp://www.pat.nhs.uk/uploads/20100603_231%20New%20%C2%A332m%20w&C%20building%20complete%20DRAFT1.pdfhttp://www.pat.nhs.uk/uploads/20100603_231%20New%20%C2%A332m%20w&C%20building%20complete%20DRAFT1.pdfhttp://cdn.hm-treasury.gov.uk/sr2010_chapter2.pdf


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I believe that the consultation process in 2009 and 2010 was / is inadequate because both

documents lacked detail e.g. no comprehensive demographic or epidemiological assessment, lack of

detail in terms of an impact assessment.

In short no one in their right mind would make a judgement call as to the wisdom of the favoured

option verses the alternatives. If these documents were a prospectus for investors on the stock

market they would bomb no one would put their money in because of lack of basic information.

Public Transparency and a Modern consultation process.

In line with the Governments views on Localisation I feel we should try to widen the process of

participation beyond the public meeting road show method and focus group meetings.

I think that the following consultation programme would be better:

Prepare a consultation document with all necessary public health, demographic,

epidemiological clinical and financial information in one place agreed before hand with

Shropshire Council and Telford and Wrekin Council. This document to be put on line as a

reference source and made available in public libraries.

Prepare an option appraisal of the three principle options noted above. NHS management to

leave out any reference to a preferred option. Issue as a paper and online consultation

document.

Place all working documents used by NHS planners on line for the public to view.

Place all written consultation comments and any NHS replies on line.

Provide a moderated online public discussion area plus a Q & A Facility.9

Tap into the massive democratic resource we have in the county and ask each parish / town

council Chair person to:

a) Have the consultation document discussed at a public parish / town council meeting.

b) Attend a NHS run meeting to give verbal and written feed back from their community.

At the end of the process the SaTH Board will:

Not be in a position where anyone can claim a done deal / fix has been agreed.

Have a good idea of what ideas and concerns people have.

Have open public evidence to show SC and T&W scrutiny committee what people think.

9The NHS has an on line facility which is more about giving the party line e.g. Mr. Cairns letter to the press

than sharing corporate the knowledge and public views.http://www.ournhsinshropshireandtelford.nhs.uk/news/News-Archive.aspx
http://www.ournhsinshropshireandtelford.nhs.uk/news/News-Archive.aspxhttp://www.ournhsinshropshireandtelford.nhs.uk/news/News-Archive.aspxhttp://www.ournhsinshropshireandtelford.nhs.uk/news/News-Archive.aspx


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Have use the Internet to engage as widely as possible with the public (68% of Shropshire

people have home access to the Internet. 100% have access via the library service.)

Be in a position to make an informed decision which is transparent and is as fair as possible.

bring people and communities with them through the process of change so that they have a

strong mandate to act and take difficult decisions on behalf of local people and

communities10

10Page 6

http://www.shropshire.nhs.uk/Documents/docs_common/Have%20Your%20Say/FINAL%20Involvement%20toolkit%20Nov%2010.pdf
http://www.shropshire.nhs.uk/Documents/docs_common/Have%20Your%20Say/FINAL%20Involvement%20toolkit%20Nov%2010.pdfhttp://www.shropshire.nhs.uk/Documents/docs_common/Have%20Your%20Say/FINAL%20Involvement%20toolkit%20Nov%2010.pdfhttp://www.shropshire.nhs.uk/Documents/docs_common/Have%20Your%20Say/FINAL%20Involvement%20toolkit%20Nov%2010.pdfhttp://www.shropshire.nhs.uk/Documents/docs_common/Have%20Your%20Say/FINAL%20Involvement%20toolkit%20Nov%2010.pdfhttp://www.shropshire.nhs.uk/Documents/docs_common/Have%20Your%20Say/FINAL%20Involvement%20toolkit%20Nov%2010.pdf


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The remainder of this paper is a critique about SaTH and the PCTs approach to consultation and lack

of openness. It gives some insight as to why I have made the comments I have on page 7 and 8

above.

The debate about replacing the Maternity and Paediatric Unit is welcome but a bit late in

the day. Around four years ago a structural report about the RSH maternity building was

prepared for the SaTH Board. There were a number of recommendations like do not drill

holes in the structure, worry about asbestos was noted, as was movement in the building.

Only now do the public know that this building should be demolished.

In the consultation document of 2009 the proposed options under consideration were:

Option 1 RSH - Level 2 A and E with acute surgery, inpatient paediatrics, obstetrics and neonates

Option 2 PRH - Level 2 A and E with acute surgery, inpatient paediatrics, obstetrics and neonates

At that time the public were led to believe that option 1 was the right thing to do in the interest of

all the people in the SaTH catchment area. The tune has now been changed.

The option appraisal on these two options showed the following:

Option 1 RSH Option 2 PRH

Non FinancialBenefit Score

694 634

Capital m 18.2 47.1

RevenueImpact ofcapital m

0.9 2.2

Constructionperiod (years)

2 3

Of the18.2 million capital in RSH Option 1, 7.5166 million (41.3%) was to be spent on re-providing

Paediatric services at RSH, the fact that the whole of the Women and Childrens Unit at RSH needed

demolishing (as now declared by SaTH during public meetings) was hushed up.

Had the fact about the need to entirely replace the Women and Childrens Unit beendeclared in the 2009 consultation document we would have had a different consultation in

2009 /10 because the capital figure under RSH Option 1 would have been at least as much

as under PRH Option 2.

It now appears that a similar scheme as that which was proposed at PRH in 2009 at a cost of47.1 million will now cost 28 million in 2010.

Keeping Women and Childrens services at RSH would have cost, in 2009, 18.2 million and

now in the 2010 consultation document it will cost 60 million.


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Capital figures quoted in the 2009 and 2010 consultation documents tell diametrically opposed

stories.

47 million to move Maternity etc to PRH in 2009 conclusion too expensive.

In 2010 60 million is needed to keep Maternity services at RSH - conclusion too expensive.

The numbers and conclusions appear to move in line with what ever party line SaTH et al

choose to take. On the face of it behaviour like this suggests a behind closed doors decision

making dynamic as opposed to a public, rational and evidence based dynamic.

It would be fair to say that the current consultation document has some odd claims aboutwhat is and is not feasible.

The cost of this scheme (and some other changes to buildings that would be necessary as

part of the preferred option) is estimated to be 28 million - a figure that can be afforded.

The cost of rebuilding the maternity unit at the Royal Shrewsbury Hospital site is estimated

to be close to 60 million, which is not affordable.

I found the figure of 60 million to be a bit excessive.

A quick search on the Internet has provided some details of the situation else where in the country.

Women and Childrens Unit Manchester.

In Manchester a new Women and Childrens Unit was opened in the summer of 2010 it cost circa32 million

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The new development is of a similar size as the one we need to replace the building

at RSH. The Manchester Unit can cope with a maximum of 5,500 births per annum13

. The unit in

Manchester will provide a full range of high quality services to women, children and babies

including:

Brand new Childrens Day Surgery Unit

Kids Observation and Assessment Liaison Area (KOALA)

Childrens Inpatient Unit

New antenatal ward

New postnatal ward

New delivery suite/labour ward and operating theatres

New Neonatal Unit/ Special Care Baby Unit (SCBU)

New midwife-led birth centre

Artistsimpression of the new Women and Childrens Unit North Manchester Hospital

11Source

http://www.pat.nhs.uk/uploads/20100603_231%20New%2032m%20w&C%20building%20complete%20DRA

FT1.pdf12

Source http://www.pat.nhs.uk/uploads/20101021_A3%20NMGH%20generic%20poster%20new.pdf

13Email from E Stringer Interim Head of Midwifery North Manchester General.
http://www.pat.nhs.uk/uploads/20100603_231%20New%20%C2%A332m%20w&C%20building%20complete%20DRAFT1.pdfhttp://www.pat.nhs.uk/uploads/20100603_231%20New%20%C2%A332m%20w&C%20building%20complete%20DRAFT1.pdfhttp://www.pat.nhs.uk/uploads/20100603_231%20New%20%C2%A332m%20w&C%20building%20complete%20DRAFT1.pdfhttp://www.pat.nhs.uk/uploads/20101021_A3%20NMGH%20generic%20poster%20new.pdfhttp://www.pat.nhs.uk/uploads/20101021_A3%20NMGH%20generic%20poster%20new.pdfhttp://www.pat.nhs.uk/uploads/20101021_A3%20NMGH%20generic%20poster%20new.pdfhttp://www.pat.nhs.uk/uploads/20100603_231%20New%20%C2%A332m%20w&C%20building%20complete%20DRAFT1.pdfhttp://www.pat.nhs.uk/uploads/20100603_231%20New%20%C2%A332m%20w&C%20building%20complete%20DRAFT1.pdf


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Had the Manchester capital cost, which is an actual rather than estimated spend, been

noted in the current consultation document there is a possibility that two options would

have been put forward for public consideration in the 2010 consultation document i.e.

Option 1: the favoured option as per the current 2010 consultation document.

Option 2: the reverse of option 1 with vascular, upper gastro-intestinal surgery and colorectal

surgery going to PRH with a part day Paediatric assessment ward and out reach Paediatric coverprovided from RSH to PRH

The fact that Option 1 & 2 above are both viable must raise serious doubts about the rigor

applied to preparing the 2010 consultation document.

Both the October 2009 and December 2010 consultation documents were / are inadequate

for strategic corporate decision making purposes affecting a vital public because they avoid

and fail to answer the most fundamental question - can we continue to have a dual system

of Acute services in Shropshire?

A comparison of the two consultation documents (2009 & 2010) clearly shows that NHS

management has an emergent approach to strategic planning. The emergent approach tostrategic planning is some times described as flavour of the month planning

14which can

be a very risky management approach to planning when dealing with major long term

decisions with life and death implications for around 500,000 people.

It is very unfortunate that the picture of what the hospital service should look like in the

future has not been properly articulated in the current consultation document. Indeed the

idea of considering or explaining the future beyond a quick fix model is studiously avoided

and dismissed on the grounds of difficulty in obtaining the necessary capital.

14Guide to Business Planning. Authors: Friend & Zehle. Pub.- The Economist. 2004. Also know as pick a

victim planning.


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I would agree that the latest proposed configuration of hospital services does have some

internal intellectual logic in it since there is what could be described as a shared pain

philosophy of planning evident in the 2010 consultation document. The model also helps

SaTH to secure a solution to some of its immediate safety problems and licensing issues

whilst, at the same time, positioning it to centralise services further on at some time in the

future.

If one DGH is the ideal long term strategic position as noted in Option 3 of the consultation

document then the democratic process dictates that SaTH should be clear about its

intentions on this matter. To identify the ideal and not state ones long term position about

achieving it is a recipe for continued distrust and speculation.1516

Given that the decisions SaTH and the PCTs want to make will affect the lives of thousands

of people and involve vast amounts of hard earned tax payer money we must demand to

know what the end point is to be for the hospital service in Shropshire, Telford and Wrekin.

If the NHS management does not know where it wants to end up in the longer term how can

the public give informed consent to a series of tactical departmental moves and be surethese moves are sensible and use scarce resources wisely in the context of a wider plan to

stop services leaving the county?

15Please see Code of practice on Openness in the NHS:

http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_402

9974.pdf

16Shropshire Star 31

stJanuary 2011 2Battle to save services needs to be more aggressive
http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_4029974.pdfhttp://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_4029974.pdfhttp://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_4029974.pdfhttp://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_4029974.pdfhttp://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_4029974.pdf