Don’t poison the wells of public engagement

Lewisham A&EIs Lewisham Hospital a victim of what might be called “mission creep through the back door”?  It certainly looks  like it.  It was never part of the remit for sorting out the bankrupt and non-viable South London Hospital Trust (SLH) – which in retrospect should never have been created from several institutions which were failing themselves –  but it has been sucked in to the “preferred solution” in a very big and  destructive way.  No wonder local people and the new-minted Lewisham CCG as well as Lewisham Council are very upset by the future that has been mapped out for them.

The Trust Special Administrator’s report addressed the SLH failure issue. But what it also did was spill over in a very messy way into the much bigger and highly politically charged question of reconfiguring London’s acute care. That’s where the dangers arise for the future of engagement when it is done badly as it was in this instance.

“Perpetuating mediocrity” is not the issue

No one wants, in Sir Bruce Keogh’s phrase, to be “perpetuating mediocrity” –  in A&E or maternity services in particular.  However, as Sir Bruce must know from his perspective as Medical Director of the new NHS Commissioning Board, and about to lead a review of urgent and emergency care service in England,  there are ways to do things and ways NOT to do things if you want them to be successful.  It really matters how things are done and seen to be done.  And in the case of yoking Lewisham hospital to the “solution” for South London Hospitals Trust, it is a case of doing things so badly that there is a real danger that the wells of public engagement will be fatally poisoned.

For a host of reasons, pressures on acute services and maternity services in London are rising, so it is hard to see there is a case for Lewisham’s A&E, in the middle of a deprived part of London, to be downgraded to an “urgent care centre” or for its consultant-led maternity unit to morph into a midwifery unit.  If that has to be the “solution” for the failed trust down the road, then the logic is pretty opaque. Especially as it is emphatically not what local people and clinicians said they wanted.

Making such recommendations for Lewisham was outwith the terms of reference for the Trust Special Administrator.  No evidence of a clinical nature was produced to support the recommended Lewisham changes and – most tellingly – it runs directly contrary to what local people AND Lewisham CCG AND Lewisham Council all want. Lewisham Hospital Trust (not an FT, no PFI obligations, so its assets are vulnerable) is, by all accounts,  a good performer and is solvent. It does not have any problems that need “solving” in this draconian and high-handed way.

So much for the “four tests”? 

Mr Lansley when in office made much of reconfigurations having to satisfy the “four tests” and rightly so.  Mr Hunt has said he will uphold them.  They are:

  • support from GP commissioners
  • strengthened public and patient engagement
  • clarity on the clinical evidence base
  • consistency with current and prospective patient choice.

As far as I can see, the changes being recommended for Lewisham Hospital fail on all four counts.  The fact that local GP clinical commissioners are so strongly opposed has to be significant. The CCG Chair Helen Tattersfield has written eloquently about this. She makes the case for resisting this change so that the CCG can have the chance to do the job they were put in place to do.  She is right to say this and the CCG deserves support.

Mr. Hunt has to decide this issue by 1st Feb.  If he backs the TSA report as it stands, the risk is it will pull the guts out of CCG confidence in London.  If he steams ahead, undoubtedly Lewisham Council will launch a judicial review with a good chance of success, but the damage to CCG and public confidence in the NHS reforms will have been done.

The only real solutions are co-produced ones

Would I be out on the street with a placard to “Save Lewisham Hospital”? Yes, but not because I am a fan of this or any other particular hospital.  I would be there because this change is happening in a very wrong way which endangers the credibility of meaningful public (and clinical) engagement itself.

It is axiomatic that there must be a proper and inclusive deliberative process involving everyone concerned about what the future needs and reconfiguration of acute services in that and every other borough should be.  There must be no “throw away people” whose views do not matter.  Anything else makes a mockery of engagement and simply drives local people and local clinicians away from engagement itself. They are not likely to return.  This is the very opposite of what we need in order to make the big changes that must be made in the way the local NHS operates particularly in London.

Good advice to Mr Hunt is “stop digging the hole even deeper”.  He should not shortsightedly insist on using the mangling of a viable local service as a solution – which may not even work financially according to an analysis by the HSJ – to a problem that already has a clear “close down” solution mapped out for it in the TSA report.

Mr Hunt should take Lewisham Hospital out of the  SLH equation and let Lewisham people decide the destiny of their own services, led by vigorous engagement and co-produced options through the Clinical Commissioning Group, Local Healthwatch and the Council.

If local people and local leaders from all parts of the lay and clinical communities are not given the freedom to try to find a solution that works for them, then they cannot be blamed for resisting an imposed one. If that happens, we will all be the poorer for it.

The Moore Adamson Craig Partnership supports user and public participation,  trains lay representatives and develops responsive  health, care and education organisations.  Feel free to contact us to discuss the opportunities.  Follow MAC on Twitter @publicinvolve

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