A public consultation by NHS Gloucestershire (the PCT) has the title Your NHS to give the impression that public engagement is important, but in this consultation the PCT only offers the public a restricted menu of choices, backed up by restricted information, and it’s pretty clear that the final choices have already been made.
A fundamental problem for NHS Gloucestershire is that there are two main hospitals just 8 miles apart in Cheltenham and Gloucester. It would make strategic sense to treat them as a single split-site hospital, so that specialist services treating few people would never be duplicated on both sites.
The perception in the PCT is that public opinion would be against this, and they dare not suggest it. So instead of a clear overall strategy for reducing duplication, they approach it piecemeal.
This consultation concerns the consolidation of three specialist diagnostic services — for stroke, breast cancer and children’s emergencies. All three are currently duplicated. All three are going to be consolidated on one or other of the sites.
To confuse things, the consultation also asks about care for major trauma (like serious or multiple injuries). There are no actual plans for trauma care on offer because discussions in the PCT are at such an early stage.
Confusing things further, the Your NHS (PDF) booklet contains detailed information about ongoing developments in community services that are not part of the consultation at all.
The diagnostic challenge in stroke care is that there is no way to tell whether the stroke was caused by bleeding or by a blood clot without doing a brain scan. The scan requires special equipment (some kind of MRI is best), and specially trained staff to interpret the results.
If the stroke was caused by a blood clot, then a clot-busting drug should be given within three hours of the clot originally forming. If the stroke was caused by bleeding, then the clot-busting drug would be fatal.
For patients arriving by ambulance from rural Gloucestershire, around half of that three-hour window can be taken up by transportation. So there’s an hour or so left to determine whether the condition is stroke at all, and to do the scan and interpret it.
Although Gloucestershire has had a 24-hour diagnostic service for stroke since January, it is still failing to provide brain scans within the hour for more than four out of every five patients. The booklet gives no explanation for the failure, and it proposes no solution.
Following the emergency diagnosis and initial treatment, stroke care is best provided in a specialist stroke unit, not a general ward. Gloucestershire fails on this too, transferring nearly three quarters of patients with strokes to general wards (even if they later move to stroke units). The booklet gives no explanation or solution for this failure either.
…still less than 20% of patients are being scanned within one hour of arrival and less than 30% are being admitted to a specialist stroke unit, rather than another ward, within 4 hours of arrival.
The PCT’s proposal is to close one of Gloucestershire’s stroke units. Some patients will avoid an 8-mile journey to a stroke unit after diagnosis.
The only way the proposal could possibly help is if it reduces staffing problems, but that only makes sense if staffing problems are to blame for the failures in care. The implication is that the 24-hour service was set up without adequate staff in the first place.
Another interpretation is that the closure of one stroke unit is part of a general strategy to avoid duplication between the two sites, and the promised improvement in care is just sugar coating to avoid a public outcry. In that case it is not clear whether the closure of one stroke unit will really help to improve care at all. The present failure to provide adequate care might be the result of other things, not the result of inadequate staffing.
The consultation seems deliberately confusing. Indeed, it’s even more confusing than my description here because it weaves “mini-strokes” (TIAs) into the plot, claiming that the changes will improve care for TIAs too but again without fully explaining how.
One thing that the consultation does make clear is that someone should be keeping a very close eye on stroke care in Gloucestershire over the coming months, ready to blow a loud whistle if things don’t improve. That someone is unlikely to be the LINk, unfortunately.
HealthWatch Gloucestershire, when it comes into being, will need the resources to keep watch on every case of this kind. That will make it a much bigger and more complex operation than the LINk is now.
The situation with breast cancer diagnosis is similar in a way. There are four centres where breast cancer can be diagnosed, but only one of them has a working machine for performing scans. Additional machines would be expensive.
…the mammography machine at [Gloucester] failed a quality assessment test and has been out of service for diagnostic purposes since February 2011…
Each mammography machine costs around £200,000. The machines have to be operated by skilled radiographers who are in short supply
It’s clear that every patient has to go to where the machine is to have a scan. The question is whether to allow them to attend one of the other three centres for the rest of the diagnostic procedures.
But the consultation does not ask that question. Instead, it asks whether to spend money on extra machines or extra centres. Putting the question that way makes it seem that having just one centre is the best choice.
Again, the consultation seems deliberately confusing. It claims that consolidating all the diagnosis in one centre will reduce delays, but it does not specify that delays are a problem as things are, or how any improvement will actually take place.
Strategically, consolidation of this specialist service makes perfect sense, but the PCT does not present it as strategic. Rather, it seems to be sugar-coating the strategy by presenting it in a different way.
Someone should be keeping a very close eye on breast cancer diagnosis, too. The implication is that there are now unnecessary delays, and no practical plan for reducing them.
Serious emergencies involving children and young people apparently require specialist diagnosis and care that cannot be provided by general A&E. As with the previous diagnostic services, Gloucestershire has two paediatric assessment units (PAUs) in the two hospitals and the plan is to close one of them.
However, neither of the existing PAUs operates 24 hours a day, only one of them operates at weekends, and only one of them has inpatient beds for children. Also, the number of specialist staff available for PAUs is set to fall because of a national training strategy.
It is becoming increasingly difficult to ensure we have appropriately trained staff in both units. This will get even more difficult as nationally the number of children’s doctors in training, who play an important part in supporting all of our children’s services, is reducing...from 16 to 12.
Again, consolidation of this specialist service makes perfect strategic sense, but the PCT does not present it as strategic, explaining it instead in terms of staffing problems. It claims closing one of the PAUs will allow the other one to operate 24 hours a day, without actually explaining how the staffing numbers add up.
At present, one PAU operates for 55 hours a week, and the other for 70 hours during the week and another 26 hours at weekends. That’s 151 hours. The new service will operate for 168 hours a week with fewer staff. It makes no sense.
Someone should be keeping a very close eye on paediatric assessment, too.
Engaging the public in decision-making is a fine thing if it’s for real. This consultation concerns decisions that have almost certainly been made already.
The public deserve to be told when there’s an overall strategy linking decisions together, such as a strategy for consolidating specialist services in Gloucestershire’s two main hospitals, which many people would regard as sensible.
The public deserve to be reassured that there is good clinical judgement behind the decisions being made. Who are the lead clinicians involved? Let’s have names, photographs and quotes from them.
HealthWatch Gloucestershire, when it eventually exists, will have a lot of work to do watching the many separate services involved in health and social care. This consultation suggests there has been a tradition of creating services that do not work properly, and that have to be redesigned later.
Many PCT personnel who are used to going about things in certain ways will transfer to the new consortium expecting to carry on just as they always have. HealthWatch Gloucestershire will have to watch out for that happening, and help to ensure that services better reflect what clinicians and the public want.