Claudia Webbe MP Member of Parliament for Leicester East House of Commons, London SW1A 0AA
Building Better Hospitals for the Future (reconfiguration) Introduction and Executive Summary The Building Better Hospitals for the Future is a positive sounding name for a reconfiguration of services. However, it will result in the vast majority of acute hospital and maternity services moving from Leicester General Hospital (located in Evington, Leicester East) to new units at the Leicester Royal Infirmary (in the City Centre) and to Glenfield Hospital (on the outskirts). This will leave a diabetes centre, possibly a GP hub and the possible relocation of the midwifery-led unit from St Mary’s Hospital, Melton Mowbray to the Leicester General Hospital campus subject to consultation. All remaining NHS land and property not required will be sold and travel time increased with additional cost to patients and their Carers. The Health and Social Care Act (2012) placed responsibilities on Clinical Commission Groups (CCGs), amongst others, to "demonstrably take account of inequalities in access to and outcomes of healthcare". It is worth bearing in mind that CCGs have been left with a duty to promote health services but there is no longer a duty to provide those services. The Consultation process is being conducted at a time when Leicester is in the midst of a pandemic and has been particularly hard hit. The report from Public Health England specifically states, “There is clear evidence that COVID-19 does not affect all population groups equally. Many analyses have shown that older age, ethnicity, male sex and geographical area, for example, are associated with the risk of getting the infection, experiencing more severe symptoms and higher rates of death.” In addition, the further impact of the lockdown is that regular face-to-face exchanges at a public venue cannot take place and on-line engagement is limited and not accessible by all. The CCG must conduct the consultation fairly and ensure that the ‘Gunning Principles1’ are adhered to and that adequate time is given for consideration and response. The Equality Impact Analysis (assessment) is a tool to ensure due regard be given to any impact of the proposal on people with protected characteristics and vulnerable groups. The assessment conducted in 2018 highlighted impacts upon the general population, however the significance of any impact would have been magnified if the assessment looked at ward2 level impacts, focusing on the local population and the proportion in those areas that suffer from health inequalities. 1
the founding legal principles applicable to public consultation in the UK In Leicester East, the 7 wards are Evington; Belgrave; Rushey Mead; Troon; Thurncourt; Humberstone and Hamilton; North Evington 2
Claudia Webbe MP Member of Parliament for Leicester East House of Commons, London SW1A 0AA
The Demographics and the health inequalities must be considered for future demand. There is a need to ensure reconfiguration has taken full account of the current and projected population changes, the under 20 population and over 65 population will increase that indicates an increased need for maternity services throughout the city and county specifically taking into consideration where this particular demographic is located. There is a need to consider the negative impact the proposal would have on those with health conditions related to health inequalities and the prevalence of those on the BAME population particularly near/around the General Hospital. Overall, most of the health indicators are significantly worse in Leicester than the England average. This should indicate the need for more and better sustainable Emergency care not less. The reconfiguration does not seem to be based on any robust needs assessment of the population that would give confidence in the proposed reduction in services. In relation to Patient need, the planned restructure of hospital services does not appear to have been formulated on the basis of patient need, resulting at best and only potentially on improved quality of care, addressing staffing problems and addressing waiting times. The proposal points to other economic or even financial factors playing a significant, if not decisive role adversely impacting on some of the most deprived communities in Leicester. In relation to value for money, the plan for the reconfiguration also includes selling off, the land around The General hospital, when the land is sold it will never come back. Any potential for catering for the needs of an expanding population and their health needs with regards expanding the Royal Infirmary in the future will be very limited by the location in the city centre due to the already existing built environment. The likely return on this investment does not seem like value for money, based on the strength of the existing evidence it is only likely to create a limited number of additional beds. The National Audit Office should be asked to undertake a review of the value for money of the Building Better Hospitals for the Future reconfiguration. There are valid concerns that the number of beds proposed for the new-look General are entirely inadequate and that the projections are based on the unrealistic hope that community care will be able to make up the shortfall. Given the coronavirus pandemic and the crisis we face in social care, this is highly unlikely and will place vulnerable people with significant underlying health concerns at further risk. The proposals were also drawn up before the coronavirus pandemic, and before any public inquiry and lessons learnt review and whilst I have advocated for additional funding there is very little evidence of the government providing this towards enabling our hospitals to be pandemic-ready for the future.
Claudia Webbe MP Member of Parliament for Leicester East House of Commons, London SW1A 0AA
The Proposal The Government has given £450m to embark on a major programme of reconfiguration. The proposals include reshaping acute and maternity services by moving all acute care to the Leicester Royal Infirmary and Glenfield Hospital. New hospital buildings would be built on these sites for maternity, children’s and planned care services The reason It is believed the plans would enhance the care provided to critically ill patients with our intensive care capacity doubled for the most unwell patients. The Plan The Leicester General Hospital, Leicester General Hospital will close as an acute hospital and most of the site will be sold for other use. Some non-acute services would be retained and the consultation would help to decide what these should. A midwifery-led unit may be re-located to Leicester General Hospital on a trial basis. Leicester Royal Infirmary, moving all acute care to the Leicester Royal Infirmary (in the city centre) and to Glenfield Hospital. All maternity services will be transferred into a new maternity hospital on the site of the Royal Infirmary, with the possible exception (pending the outcome of the consultation) of a midwife led unit on the site of the General though this may turn out to be temporary. Glenfield Hospital, there will be a new planned care Treatment Centre St Mary’s in Melton Mowbray re-locate the midwifery-led unit to the Leicester General Hospital
Claudia Webbe MP Member of Parliament for Leicester East House of Commons, London SW1A 0AA
The issues 1.
The Consultation process
Law of Consultation set out in the Gunning Principles is a set of rules for public consultation in R v London Borough of Brent ex parte Gunning [1985]. They consist of four rules, which if followed, are designed to make consultation fair and a worthwhile exercise: • that consultation must be at a time when proposals are still at a formative stage; • that the proposer must give sufficient reasons for any proposal to allow for intelligent consideration and response; • that adequate time is given for consideration and response; and • that the product of consultation is conscientiously taken into account when finalising the decision. There has been a great deal of concern about the consultation process where people have not been able to join in consultation events. Particularly as the COVID19 pandemic has meant Leicester has been continuously in some form of lockdown and/or significant measures since March 2020 and the current second wave. In addition, the disproportionate impact of the pandemic on BAME communities (Public Health England) should be considered and given due regard as it would possibly impact on the response to the consultation process. It is a genuine concern as to the efficacy and fairness of consultation during lockdown, given the fact that face-to-face meeting and debate is not possible, and many people will not be able to access their online events (see response in the Leicester Mercury – 14/11/20). This mirrors the concerns many residents have raised with me about their inability to access the online consultation meetings and the difficulties they describe about trying to “logon”. If the CCG mean to abide by the Gunning principles they could pause the consultation process or extend it due to the impact of the pandemic. This would also provide the CCG the opportunity to be clearer in the consultation process with appropriate translations of the full text as well as summaries made available in areas of high concentrations of BAME communities. 2. Equality Impact Analysis There is widespread concern and continuing criticism as to the public consultation exercise. The CCG would probably argue that the engagement process began in
Claudia Webbe MP Member of Parliament for Leicester East House of Commons, London SW1A 0AA
2014, with an initial Equality Impact Analysis undertaken in 2018 to ensure there would be fair access for everyone and thus to avoid inadvertently excluding any particular groups of people. However the Equality Impact Analysis is a tool by which information should be sought and due regard be given to any impact of the proposal on the people with a protected characteristics. This is a requirement under the public sector duty (s. 149) of the Equality Act 2010. Furthermore, case law prior to the Equality Act 2010 has provided a set of principles which describe the legal expectation of due regard as set out in section 149 of the Equality Act. These principles, known as the Brown Principles (Brown, R v Secretary of State for Work and Pensions [2008] EWHC 3158 (Admin)) state that in order to meet the duty, public bodies must ensure: Decision makers should be aware of the implications of the duty when making decisions about their policies and practices; The duty arises before and at the time that a particular policy is under consideration and a decision is taken; the duty must be exercised with rigour and with an open mind; the duty is a continuing one and transparency about how decisions are reached. It is imperative that the Equality Impact Analysis process be done well and with rigour. There are clear implications that the proposals will have an adverse impact on age due to the ageing population and race/ethnicity due to the disproportionate amount of Black, Asian & Minority Ethnic (BAME) people, particularly in the east of the city. In addition there could be potential for pregnancy and maternity discrimination as services are being withdrawn. The recommendations from the Equality Impact Analysis (assessment) published on 31 July 2018 mainly centre on “next steps for the formal consultation work. Future consultation work is required to meet the requirements of equality legislation. Following formal consultation, a post consultation EIA should be undertaken. This should include additional information on potential impacts that have been identified within consultation work” (Midlands and Lancashire Commissioning Support Unit) The main findings of the assessment is that information at that time (2018) and the limited engagement work at that time did not highlight any significant adverse impact or disadvantages for people within protected groups. However, there was impact upon certain groups such as the additional travel, additional costs and additional time for Disabled people, older adults, pregnant women and Carers. The Equality Impact Analysis did not look into the specific communities that use or are in the vicinity of Leicester General Hospital, these will include a significant older BME (nonEnglish speaking) population who live in extended family groups who act as their Carers. The Equality Impact Analysis did not consider the specific disabilities in the area (east Leicester) and the specific chronic diseases that would disproportionately impact on the (Asian) communities that live there. In addition, there may be a higher birth rate and there is certainly greater deprivation and poverty in east Leicester.
Claudia Webbe MP Member of Parliament for Leicester East House of Commons, London SW1A 0AA
3. Demographics and health inequalities The Building Better Hospitals for the Future reconfiguration proposals are not based on any robust needs assessment of the population that would give confidence in the proposed reduction in services. There is a need to ensure reconfiguration has taken full account of the current and projected population changes. The demographic or the populations of Leicester must be given due regard it is both very diverse and susceptible to changes. The Joint Strategic Needs Assessment highlights: •
Leicester has a population of 355,218. The city is relatively young compared to England, with student populations and inward migration acting as contributing factors.
•
The under 20 population and over 65 population will increase and this means those regularly accessing education, health services, and social care are likely to increase at a faster rate than those in employment.
•
Leicester is home to many communities, including different ethnicities, faiths and sexualities. Over half (55%) are from non-White British backgrounds, three quarters express a faith, and 4% are LGBT.
The chart in Appendix A shows the local health need in relation to the England average (Public Health 2019). The reconfiguration has to give due regard to the specific health needs of the BAME and the ageing populations (and the other Protected Characteristics) to ensure that it does not have a disproportionate adverse impact. Leicester City is significantly worse than the England average for most of the diseases that disproportionately impact some communities more including: • • • •
Emergency hospital admissions for all causes (SAR), Hospital admissions for Congenital Heart Defects Emergency hospital admissions for Chronic Obstructive Pulmonary Disease (COPD) Hospital admissions for Myocardial Infarction (heart attack)
The emergency admissions into hospitals and the death rate for many conditions are significantly worse than the England average. In general most of the health indicators are significantly worse in Leicester than the England average. This should indicate the need for more and better sustainable Emergency care not less. The CCGs have legal duties under the Health and Social Care Act 2012, with regard to reducing health inequalities between patients in access to, and outcomes from healthcare services, and to ensure services are provided in an integrated way where this might reduce health inequalities.
Claudia Webbe MP Member of Parliament for Leicester East House of Commons, London SW1A 0AA
• It is a moral imperative concerning social justice. The issue should be of great importance to a caring and compassionate service. • It is a legal requirement. The Equality Act 2010 also states that public bodies must demonstrate that due regard is given to the protected characteristics of any adverse impact (generally conducted by an Equality Impact Analysis). • It makes good business sense. The burden of ill health and disability, as well as premature mortality, is disproportionately focussed on the most deprived populations. These sections of society are least equipped and resourced to make best and most appropriate use of services. If the ‘unmet need’ for preventive services and those for early detection and management is not addressed in those at greatest risk, a large part of the growing burden and cost will persist. (NHS Right Care, Equality & Health Inequality Pack). The proposal will potentially create an increased travel journey for approximately 30% of patients living in Leicester, Leicestershire and Rutland who need acute hospital care. The reconfiguration does not seem to be based on any robust needs assessment of the population that would give confidence in the proposed reduction in services. There is a need to look further and deeper at the population needs and composition at ward level to highlight any specific or pockets of health inequalities.
4. Patient need CCGs have been left with a duty to promote health services but there is no longer a duty to provide those services, as there had been a duty incumbent on the Secretary of State and area-based health services since 1948. That duty has now been totally abolished by the Health and Social Care Act 2012. “There is no duty to provide. They (CCGs) have a duty to arrange, which is contracting those services, and an overarching framework duty of a duty to promote.” (Professor Allyson Pollock, from Queen Mary University of London) The planned restructure of hospital services does not appear to have been formulated on the basis of patient need. The proposal points to other or even financial factors playing a significant, if not decisive role adversely impacting on some of the most deprived communities in Leicester. These communities are also the communities with the most acute healthcare needs and with the greatest health inequalities as shown by the Indices of deprivation (Appendix B).
5. Value for money The plan for the reconfiguration also includes selling of the land around The General hospital. The CCG suggest that this would be reinvested into the NHS but not specifying the amount or for which services. In addition when the land is sold it will
Claudia Webbe MP Member of Parliament for Leicester East House of Commons, London SW1A 0AA
never come back. Any potential for expanding the Royal Infirmary in the future is very limited by the location in the city centre due to the already existing built environment. This significant aspect of the reconfiguration has not been thought out and the land could be put to better use rather than creating additional housing stock for communities that will increase the demand but who will have limited access to acute services near their home. Many residents have stated to me that although the services are sometimes duplicated or triplicated, we have three intensive care units, one at each site that can serve the health needs of the local, diverse and growing population and will eventually be big enough in their own right and save money in the long run rather than trying to gain capacity and going through another reconfiguration again in the near future. The concern that doctors and nurses are spread too thinly may be genuine and also that there are staff shortages locally. Nevertheless, many residents would argue these are ‘Straw man arguments’ as the reconfiguration will not solve them or be sustainable in the near future, particularly as we emerge out of the coronavirus pandemic and as we face a severe economic downturn. The £450 million to implement and the likely return on this investment does not seem like value for money, based on the strength of the existing evidence it is not likely to create any sizable number of additional beds. Leicester’s hospitals say there is a need for 139 more acute beds by 2023-24 - an increase of 7% on the current number. However, at the same time reducing the services and access to acute care for a substantial population to the East of the City. The National Audit Office should be asked to undertake a review of the value for money of the Building Better Hospitals for the Future reconfiguration
6. Pandemic-ready for the future The coronavirus pandemic has exacerbated and shone a light on existing inequalities. In Leicester East, last month, over 5000 of our residents claimed unemployment benefits – a figure that has more than doubled by over 3000 since lockdown began in March 2020. This means that our community has an unemployment rate which is above the national average. The office for national statistics found that overcrowding is a growing problem in Leicester and Leicester East in particular. There are pockets of areas close to Leicester’s General Hospital with populations close to 2,000 living in an area the size of 60,000 square metres in size. This means that each person who lives in this area has an average of 32 square metres of space which is the equivalent to a box bedroom. The UK average is 3,676 square metres of space, which is over 100 times the amount of space of people living in Leicester East and the East of Leicester more generally. Given these stark inequalities it is unrealistic to expect ‘community care’ to address future needs without a substantial societal transformation.
Claudia Webbe MP Member of Parliament for Leicester East House of Commons, London SW1A 0AA
Appendix A https://www.localhealth.org.uk/#bbox=425153,323741,67494,38288&c=indicator&i=t 4.allages_chd&selcodgeo=E38000097&view=map16 CCG 2018
Claudia Webbe MP Member of Parliament for Leicester East House of Commons, London SW1A 0AA
Appendix B https://www.localhealth.org.uk/#c=report&chapter=c01&report=r01&selgeo1=ccg_20 18.E38000097&selgeo2=eng.E92000001