1. Introduction. 2. Context

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1 Shaping a Healthier Future for North West London consultation response by Richmond upon Thames Health, Housing and Adult Services Overview and Scrutiny Committee. 1. Introduction Shaping a Healthier Future is NHS North West London s proposed programme of change for both out of hospital and hospital services. This is the London Borough of Richmond upon Thames s response to the proposals. The proposals represent a radical reconfiguration of health services which have an impact on Richmond s residents particularly those in the north of the borough. Given that they will have a profound and lasting impact on local health services, services that are of the utmost importance to local people, the Council is committed to responding fully to the consultation. 2. Context Shaping a Healthier Future is NHS North West London s proposed programme of change for both out of hospital and hospital services. The proposals represent NHS NW London s response to the significant challenges facing the NHS, namely the need to improve the quality of care and reduce unwarranted variation; the need to improve the health of local people and reduce health inequality; the need to address substantial financial challenges to ensure that services and organisations are sustainable for the long term; and represent a radical reconfiguration of local health services, with an increased emphasis on out of hospital care and a reconfiguration of NW London s hospitals. The proposals set out in Shaping a Healthier Future are summarised as follows:

2 Option A NHS NW London s preferred option: Along with Hillingdon Hospital and Northwick Park, Major Hospitals 1 are: Chelsea and Westminster St Mary s West Middlesex As a result, Hammersmith would become a specialist hospital (similar to its current status) and Charing Cross downgraded to a local hospital 2. Option B: Along with Hillingdon Hospital and Northwick Park, Major Hospitals are: Charing Cross St Mary s West Middlesex As a result, Hammersmith would become a specialist hospital (similar to its current status) and Chelsea and Westminster would be downgraded to a local hospital. Option C: Along with Hillingdon Hospital and Northwick Park, Major Hospitals are: Chelsea and Westminster Ealing St Mary s As a result, Hammersmith would become a specialist hospital (similar to its current status) Charring Cross downgraded to a local hospital and West Middlesex to a Local and elective hospital 3. 1 Major hospital this is the closest to what is currently known as an acute or district general hospital, and provides most types of care, right up to highly complex and urgent services. Major hospitals also provide care for children and maternity services, since these both sometimes need complex emergency services. In these proposals these hospitals will have more senior clinicians and specialist services than now they will have investment so that they can be better than our current acute hospitals. If patients at a local hospital suddenly need more urgent or complex care, they will be transferred by ambulance to these major hospitals. Major hospitals will also provide local hospital services and mental health liaison services. 2 Local Hospital: this type of hospital provides all the most common things people need hospitals for, such as less severe injuries and less severe urgent care, non-life threatening illnesses, care for most long-term conditions such as diabetes and asthma, and diagnostic services. It basically provides the kinds of services that most people going to hospital in NW London currently go there for. 3 Elective Hospital- this hospital is where a person would go if they need an operation which is not urgent. These hospitals cover things like hip replacements and cataract operations. They are particularly good places to be treated because they are not disrupted by emergency cases which have to be dealt

3 We have been informed that, whichever option is chosen, all nine hospitals are likely to remain open as hospitals providing, at the least, around 75% of their original activity. The proposals are now subject to formal consultation, closing on 8 October This document forms the London Borough of Richmond upon Thames response to this consultation. It is presented in this form to encapsulate the whole range of issues it wishes to cover in its response, which would not be possible using the standard consultation response form provided. The London Borough of Richmond upon Thames (hereinafter LBRuT ) is determined to champion the interests of its residents by playing a full and positive role in ensuring that the people living and working in the LBRuT have access to the best possible healthcare and enjoy the best possible health. NHS NW London s proposals will have a profound and lasting impact on health services that many of our residents use; to illustrate this point more fully the table below shows the number Richmond residents who use the hospitals affected by the proposals 4 : Hospital Inpatients Outpatients Includes DNA s Outpatients Attendances only Accident & Emergency Imperial Chelsea & Westminster West Middlesex Ealing Central Middlesex Northwick Park Hillingdon No Data No Data No Data No Data 3. Case for change On 30 January 2012, NHS NW London released Shaping a Healthier Future - Case for Change 6. NHS NW London presents a compelling case why NW London s health services must change. Clinical quality is a major factor in the case for change. with before less urgent ones, and can more easily be kept clean and free from hospital infections. planned (or elected ) by a patient or their doctor 4 Data Provided from NHS SW London. 5 Imperial consists of the following hospitals: Hammersmith Hospital, St Mary s, Queen Charlotte's & Chelsea Hospital, Western Eye Hospital and Charring Cross. 6 Shaping a healthier future - NHS North West London - Case for Change (30 January 2012) is available at:

4 Richmond s Health Housing and Adult Services Overview and Scrutiny Committee understands the case for change - for local health services to improve and develop to meet the changing and growing demands of local people, against a backdrop of the increasing financial challenges that have resulted from the overall pressure on public sector expenditure - and supports the shift of care closer to home and in the community wherever possible, provided care remains to a high standard. 4. Criteria for NHS reconfigurations The Secretary of State identified four key tests for service change 7, which are designed to build confidence within the service, with patients and communities. We are pleased that clinicians have a major role in developing proposals and we expect them to be involved in explaining to the public that the proposals strive to improve patient care rather than save money. We consider the criteria used to develop the proposals fundamentally sound. We are, therefore, able to support the direction of travel underlying the consultation paper. Whatever option is chosen for changing the NHS in North West London, the remaining trusts must be financially sound. 5. Richmond s position Support We support the clinical case for change and the direction of travel towards improved out of hospital care. For NHS NW London to be able to deliver its plans the out of hospital component needs to be robust, appropriate and effective. We support Option B - as this will provide the best outcome for residents of the borough. We also support Option A, with the caveat that we have a number of concerns about accessibility for our residents where Charing Cross is no longer a Hyper Acute Stroke Unit for instance. Our concern is for the best outcome for our residents this translates, effectively, as West Middlesex being retained as a Major Hospital as 40% of our residents use it. We therefore give our support to both Option B and Option A. 7 NHS Chief Executive Sir David Nicholson outlined the criteria for NHS reconfigurations in the letter NHS Reconfiguration guidance available at:

5 Concerns From a London Borough of Richmond upon Thames perspective, the committee feels there are a number of concerns in the approach taken by NHS NW London to determine the changes that should be made. The proposals have been clinically led. We hope that the patient - all impacts as well as their experience has truly been placed at the heart of the proposals and is the focus - rather than the clinical case. We do not however, feel that this is the case for our residents for two reasons which can broadly be categorised as: Fundamental problems with the consultation process and methodology; Lack of due regard for the impact on the residents of the London Borough of Richmond upon Thames. Fundamental problems with the consultation process and methodology: Communications to residents regarding the rationale for changes in acute services and out of hospital transformation, the appropriate use of primary care and Urgent Care Centres could, as a general point, benefit from concentrated effort in communicating key messages to the general public and in particular to vulnerable communities such as the mental health community who have not been included for special consultation even though they are major users of A&E. Engagement: Many staff will be impacted by the proposed changes, for example: staff transferring to different sites; the need to recruit more consultants (paediatrics) and changes to maternity services. This will also impact on those staff at major hospitals who will see their hospitals grow in demand. The proposals have the best chance of succeeding in the implementation stage if all staff have been fully involved and engaged in the plans for change. Moreover, periphery boroughs have not been engaged adequately. The fact that Richmond residents have received little information about the consultation, the roadshow in the LBRuT was held 3 weeks before the end of the formal (14 week) consultation period and the presentation by NHS NW London to the Health, Housing and Adult Services Overview and Scrutiny Committee shortly before the consultation closes highlights this point. The location used for the road-show would not have reached sufficient numbers or relevant groups in the borough who use services provided by NHS NW London. The Chair of the Committee had, in July 2012, suggested a more suitable venue in Twickenham but this was, sadly, not acted upon.

6 Lack of due regard for the impact on the residents of the London Borough of Richmond upon Thames: Whilst Richmond is not central to the NW London review, it does not appear that sufficient consideration has been given to the impact on periphery boroughs. Nor does it appear that consideration has been given to the combined impact of NW and SW London s proposed options and the impact this will have on our residents in. We are concerned at the position we would find ourselves in if, from our perspective, the worst option for us was chosen in both NW and SW London (West Middlesex is no longer a Major Hospital and Kingston Hospital is no longer a Major Hospital). Reviews of this scale do not happen in isolation and whilst we understand the constraints, a more holistic approach to service transformation would have been beneficial to residents across all the boroughs and in ensuring that out of hospital care marries up effectively with hospital reconfiguration not just for one catchment area but for London as a whole. Therefore we recommend that: NHS NW London should work closely with colleagues from the surrounding area and NHS London to explore the implications of any reforms on patients crossing boundaries. NHS Clusters and Ambulance Services serving areas adjacent to North West London s borders to be fully involved in forward planning for the new arrangements. Joint working 'across the borders' will need to be undertaken to produce transfer protocols which will provide clarity to Ambulance Services and hospitals. We know that the consultation proposes as the preferred option, Option A. In both Option A and Option B, West Middlesex is retained as 'hot' site/ Major Hospital. If West Middlesex continues as a Major Hospital retaining A&E, Children's Services and Maternity then the 40% of our residents who use the hospital will be minimally affected. We are also aware that there is a strong (Ealing) lobby to retain Ealing Hospital as a Major Hospital (Option C). If, however, Ealing becomes the Major Hospital and West Middlesex no longer continues with effective A&E, Children's or Maternity Services this would be catastrophic to Richmond residents in terms of accessibility there will

7 be adverse impacts on ambulance, private car and public transport journeys due to the increased patient flow. Given the demographics and the proportion of older residents in our borough, there is a need to ensure availability and an increase of hospital provided transport. There are cost implications to patients and their carers, which we do not feel have been fully considered as a general point and particularly, for LBRuT residents. We recommend that NHS NWL should assess the impact of their proposals on carers, and state the actions that they will take to ensure their proposals do not increase the burden on carers Travel and equalities impact There are comparatively few hospitals to serve Richmond residents given our geographic location. We would therefore be compromised by any option other than B or A. If West Middlesex is not retained, Richmond residents would have to travel great distances to Kingston Hospital or one of the inner London hospitals for treatment. Due to our location there is extreme variability of travel times depending on whether or not the journey is during peak travel. Furthermore, the limited number of river crossing points means that the area becomes grid-locked whenever there is a problem on the routes out of London (recent examples include planned Hammersmith flyover works and M4 closures). In short, Option C would result in thousands of disenfranchised Richmond residents with no easy access to services. Another critical health concern for Richmond borough residents will be the travel times when they require emergency treatment within 30 minutes for, for example, strokes, cardiac events and major trauma. Whilst we appreciate that patients should go to the hospital best suited to deal with their condition, particularly in the case of Stroke and cardiac events, given the concerns about travel as outlined above, we are therefore concerned for residents in some parts of the borough who might be affected by Option A where Charing Cross is no longer a Hyper Acute Stroke Unit. The Equality Impact Analysis commissioned by NHS NW London, provides high level equality analysis by PCT area, highlighting geographical hotspots in which equality impacts are likely to be most pronounced. This analysis was based on travel and access data, desk research and also a review of each of the local Joint Strategic Needs Assessments (JSNAs). The analysis indicated that 91% of the local population are likely to be unaffected. However, this not only masks serious potential variations in the impact on vulnerable populations and from borough to

8 borough, it does not, we believe, include or at the least take fully into account LBRuT Residents. We would have liked to have seen a much more detailed analysis before consultation was entered into, so that local people and their elected representatives would have firm information with which to engage during the formal consultation process. Additional concerns: Both as Members of the Committee and as residents of the borough we have a number of additional concerns. These are: The ability of the NHS to cope with increasing demand and reduced budgets and the long-term sustainability of the proposals. Access to GPs and capacity of GPs to be able to help support this reconfiguration (i.e. what will be changing? (hours / capacity / method)) The need for additional emergency ambulance resources to be able to manage longer journeys across fewer emergency sites. Transport co-ordination between the hospitals, where patients are often treated at multiple sites. The implications behind telecare and the unknowns associated with innovation and healthcare. Capital funding needed to improve sites and contribute to improving healthcare services It would be useful if NHS North West London could respond with more detail on all the concerns expressed in our response. The failure to anticipate and provide all the information required and requested by the London Borough of Richmond upon Thames Health Housing and Adult Services Overview and Scrutiny Committee, on a number of occasions, in relation to the impacts of the proposed reconfiguration has been a significant cause of anxiety. We do not feel that our residents have been adequately consulted, nor do we feel the impact to us has been considered sufficiently. We would have liked to have seen a more detailed analysis and in particular, the plans to show pre- and postreconfiguration times for hyper acute emergencies that are not fully treated by the Ambulance Service (such as maternity emergencies, strokes and heart attacks). We

9 are concerned about the impact on all LBRuT residents who use (and / or are) close to Imperial's Charing Cross Hospital. We therefore recommend better analysis and further consultation of LBRuT residents. 6. Conclusion We understand that the reconfiguration of hospital services in North West London aims to deliver the best possible healthcare to patients and the public given that health needs are changing and the case for change is strong. There are a number of challenges facing the health service including demographic change, unsatisfactory access to primary care (not being able to get to see GPs and higher than average A&E attendances), issues with the quality of estates and financial challenges. Specifically, we consider that no change presents a serious risk to patient safety. As such, we realise that a reconfiguration of this scale is necessary in order to meet these emerging challenges. Our concern is for the best outcome for our residents. More information on the specific impact to LBRuT residents and a more in-depth equalities impact analysis is, we feel, required and is one of our greatest concerns with the consultation. The best outcome in the view of the proposed options translates, effectively, as West Middlesex being retained as a Major Hospital as 40% of our residents use it. We therefore give our support to both Option B and Option A. We wish to be kept informed throughout the delivery of the Shaping a Healthier Future in North West London programme and given an early indication if plans did not progress as hoped. Councillor Sue Jones Chairman of Richmond Health, Housing and Adult Services Overview and Scrutiny Committee. Richmond s member on the NW London Joint Health Overview and Scrutiny Committee. Cc. Health, Housing and Adult Services Overview and Scrutiny Director of Adult and Community Services, London Borough of Richmond upon Thames. Cabinet Member for Adult services, Health and Housing.

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