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Aim:

To maintain and develop Newark Hospital with a fully operational emergency care centre and re-open Friary Ward, either as an in-patient ward for the elderly or as a fourth medical ward.

Objectives and Recommendations for Action:

  • A ballot paper to be sent to each household in the Newark area asking whether they would like to see Newark’s A&E department to be retained and developed and Friary Ward re-opened.
      
  • Use Freedom of Information requests to obtain evidence that would assist with the campaign’s cause – for example the cost of the consultation, and whether the hospital supports or costs the NHS Nottinghamshire County.
     
  • Work with the NHS Nottinghamshire County and Sherwood Hospitals NHS Foundation Trust to draw up an appropriate Blueprint for Health Services in Newark for the next 50 Years.

 

Background to the Campaign

 

In May 2010 the new Secretary of State for Health, Andrew Lansley MP, stated on Radio 4’s Today programme “We are going to stop the removal of [local] services where, firstly, it has not been justified by clinical evidence, secondly, where there has not been the public involvement and engagement that really is necessary and where GPs as local commissioners of services have not been engaged.” The Save Newark Hospital Campaign contests the validity of the NHS Nottinghamshire County public consultation process, for reasons to be provided within this Positioning Document. We also contest many of the clinical and statistical assertions made by NHS Nottinghamshire County in the Consultation Document.

In response to the launch of the Consultation two independent petitions raised a total of 8,894 signatures in Newark between December 2009 and January 2010. The first raised over 5000 signatures, requesting that ‘Newark Hospital is maintained and not downgraded’. The second street petition gave the two options provided in the NHS Consultation document, and provided a third option requesting ‘24 hr urgent care centre, an improved service’. Of the 3394 signatories 98% chose option 3. 

Subsequently an alliance was formed to campaign to save Newark Hospital’s A&E department and Friary Ward. It followed a public meeting on 15th March at which Nottinghamshire MP John Mann shared tactics used to save Bassetlaw Hospital A&E from a similar fate in 2003. The alliance, made up of concerned residents, town councilors and health professionals asked Dr Ian Campbell to lead the campaign. A website was been set up www.savenewarkhospital.org.uk. The alliance has a formal structure, constitution and officials and is seeking charitable status.

On 6th April it was announced that local residents Cara and Maria Hansen had joined forces with the alliance, amalgamating their Facebook campaign to save the A&E department with the official campaign. They brought with them 5,500 plus members. Membership of the campaign continues to grow daily.


NHS Nottinghamshire County Proposals

 The NHS Nottinghamshire Count Board is to consider the results of their public consultation, due to be presented to the Board on May 27th 2010. The Consultation presented the following four options for Newark Hospital – two for A&E; two for Friary Ward:

Options for A&E

Option 1: Minor Injuries Unit ‘Plus’ 24/7 – a minor injuries unit (MIU) staffed by doctors and specially trained nurses to treat people with minor injuries such as broken bones and minor illnesses. There would be access to x-ray and other testing equipment. A direct online link to other centres would allow the results to be read by experts who would give immediate advice if necessary. An out of hours GP service would also be available. This service would treat 85% of patients with the other 15% taken directly to another hospital by ambulance.

Option 2: Minor Injuries Unit ‘Plus’ 7am-midnight – this would be the same as Option 1, but only open between 7am and midnight, with out-of-hours GP cover enhanced.

Options for Friary Ward

Option 1: Close Friary Ward permanently and use existing in-patient assessment beds at Ashfield Community Hospital, Lincoln or Grantham.

Option 2: Close Friary Ward permanently and transfer challenging behaviour beds to Ashfield Community Hospital and develop a small ‘step-down’ unit in Newark.

Both options would include providing NHS day services at Byron House, Newark, and developing community services to enable more people to be supported at home longer.

Results of the consultation are to be taken to the Board on 27 May 2010 and an extraordinary Board will decide on the proposals on 17th June 2010. If the suggested proposals are approved by the Board of NHS Nottinghamshire County the reduced A&E service at Newark Hospital is likely to be implemented by the end of 2010.

The Missing ‘Option 3’

The Save Newark Hospital Campaign proposes a third option for A&E – returning Newark Hospital to a fully operational Emergency Care Centre where an integrated emergency service will provide comprehensive care to all but the most seriously ill, or those requiring immediate and direct access to specialist centres, far in excess of the 85% of potential patients currently proposed by NHS Nottinghamshire County (discussed in detail within this document)

Friary Ward should be re-opened to provide a healthcare for the elderly unit or as a fourth general medical ward. This could provide an additional 15 beds. Byron House should provide NHS day services and a further development of the community services that would enable more people to be supported at home.

 
The Consultation Process Argument

 The Campaign believes the NHS Nottinghamshire County Consultation process has been fundamentally flawed, in places misleading, and therefore its subsequent findings discredited. With reference to Better Together, the Consultation has failed to adhere to government guidance on public consultation on the following points:

Criterion 1: When to consult

Formal consultation should take place at a stage when there is scope to influence the policy outcome.

The consultation has taken place too late in the planning cycle.  There has been no opportunity to influence policy outcomes. The public has been presented with two predetermined options from which to choose, not asked for their open opinion on the future of services at Newark Hospital.

Criterion 3: Clarity of scope and impact

Consultation documents should be clear about the consultation process, what is being proposed, the scope to influence and the expected costs and benefits of the proposals.

Whilst the consultation document is clear about what is being proposed, the consultation is biased and misleading (see ‘Clinical Argument’ section below).

Criterion 4: Accessibility of consultation exercises

Consultation exercises should be designed to be accessible to, and clearly targeted at, those people the exercise is intended to reach. 

The consultation has not been clearly targeted and has failed to reach its target population as indicated by the low response rate. This would not be unusual if we did not already know that people in Newark care deeply about this issue. This therefore suggests that people did not feel confident in the process, in the absence of a third option. Government guidance suggests that if there is no choice then a different method of communication should be used (see Better Together page 75[1]). We contend that the process has failed because the consultation has not been clearly targeted.

Criterion 6: Responsiveness of consultation exercises

Consultation responses should be analysed carefully and clear feedback should be provided to participants following the consultation.

Once published the analysis of the results requires careful scrutiny. The consultation document states that, “We are consulting the local community between 30 November 2009 and 6 March 2010 – and we want as many people as possible to contribute“.

Only 263 responses, or just slightly more than 0.5%, had been received in the last few weeks before closure of the consultation. A telephone poll was conducted to raise a further 500 responses. It has not been made clear who responded to this telephone poll but they are not, by definition, representative of the same group of “respondents” who made their comments proactively. The 500 are in effect “non-responders” and cannot be considered as part of the consultation process. Further, the sample size, of less than 1% of the target population does not present a statistically significant sample. 

Criterion 7: Capacity to consult

Officials running consultations should seek guidance in how to run an effective consultation exercise and share what they have learned from the experience.

The consultation process should have stated that it would abide by the government guidelines on consultation in their documents. This has not been done.

 

The Clinical Argument

Deterioration of Services

Several meetings have been held to inform hospital staff of the proposed developments at Newark Hospital. At these staff engagement sessions it has been stated by Sherwood Forest Hospitals NHS Foundation Trust that none of the surgical procedures presently undertaken at Newark would be withdrawn – this includes major orthopaedic operations such as hip replacements and gynaecological procedures such as hysterectomies. However, in order to do this, particularly with overnight stays, there is a need to maintain out of hours clinical and medical cover. Withdrawing dedicated overnight cover from A&E will impact upon the ability to provide this emergency cover. The safety of some elective surgical procedures at the hospital would be questioned. Senior hospital staff have already indicated their concerns and are considering whether to withdraw some surgical services.

This would in turn lead to a gradual deterioration in the level of medical and surgical services provided, with Newark Hospital facing a gradual drawdown of services, to become in due course a large health centre or cottage hospital. Such a hospital would not meet the healthcare needs of the residents of Newark and district.

There are already signs that services at the hospital are being wound down. For example, on Thursday 8th April 2010 the operating theatre at Newark Hospital was closed all day, despite King’s Mill doing extra orthopaedic lists at the weekend. Physiotherapy and occupational health departments at Newark Hospital have been moved into smaller rooms and the staff have been told there may be redundancies. Blood group testing services were removed from Newark Hospital and transferred to Kings Mill in April 2010 and in May it was announced that out-patient pharmacy was to be closed, and the future of in-patient pharmacy services were to be put out to consultation.  It also appears that the plan to bring stroke patients back to Newark following treatment at specialist units has been shelved because of an inability to identify spare beds. It remains unanswered whether there was ever a will to make this proposal achievable.

Friary Ward remains closed. Much has been made of low bed occupancy in the weeks immediately prior to its closure. Friary ward staff have indicated there was a deliberate management policy to discourage use of Friary Ward for some months prior to the decision to close it. It seems  low bed occupancy may have been created to justify its closure.

A Newark Strategy Group was formed as part of the consultation process and front-line staff at the Hospital were invited to be involved. However we have received evidence that senior managers at Sherwood Forest

Hospitals NHS Foundation Trust actively prevented their participation. As a result meetings that have been held with frontline staff have been to inform of new models of care proposals rather than involve them in planning any changes.

The Reality – Heart Attacks and Strokes

Approximately 60% of Acute Coronary Syndrome/Myocardial Infarction patients are not suitable for surgical intervention[2]. They do not need transferring – indeed probably won’t be accepted – by a specialist centre. Yet the consultation document says all heart attack patients need surgery at Nottingham City Hospital. This gives a polarised and erroneous impression of the reality. There appears to be no clinical safety basis for saying that patients not requiring surgical intervention cannot continue to be cared for at Newark.

Similarly with strokes: thrombolysis in strokes is a new field and there are few tertiary services yet established, let alone able to accept patients 24/7. As these services get established it is unlikely they will accept all strokes and TIAs and there will be clinical exclusion criteria, so the model needs to consider where the remaining patients go. This is not clear.

Heart attacks and Strokes requiring intervention are a small percentage of patients. A service does not become unsustainable because of withdrawing (a proportion of) heart attacks and strokes.

True Picture of Demand

Currently 85% of Newark’s A&E patients have minor injuries or ailments. That means 15% of patients attending A&E have more serious problems. Two years ago new ambulance admission criteria were introduced meaning Newark A&E no longer took by ambulance:

  • Cardiac arrests
  • Patients with a Glasgow Coma Scale of less than 13
  • Patients with low oxygen saturations
  • Trauma patients and those likely to require emergency surgery

These criteria do not make clinical sense nor do they act in the best interests of the patient. They also lower the number of those who would otherwise have been treated at Newark’s A&E. Ambulance crews report receiving such criticism from line-managers for taking patients to Newark that they now use the hospital as an exception rather than the rule. We believe that plans have already been made by East Midlands Ambulance Service to divert all potential stroke patients away from Newark to other hospitals and that an aborted attempt was made to implement these plans in April 2010. This appears to be yet another example of the “Review” being implemented before the Consultation process has been completed, adding to our belief that the whole process was always a “done deal”.

For further example, if an ambulance crew know there is no chance of patient survival from a cardiac arrest it is neither fair to the staff nor the patient or the patient’s family to continue resuscitation all the way to King’s Mill or Lincoln.  Additionally many patients with Chronic Obstructive Pulmonary Disease and other chronic respiratory conditions arriving into hospital with an oxygen saturation of under 90% would respond quickly to first line treatments at Newark and do not require the non-invasive ventilation they would be given in an longer ambulance trip. Furthermore, many stroke patients will initially arrive with a Glasgow Coma Scale of less than 13. This might only mean that they are not opening their eyes spontaneously and not talking coherently. Whilst such situations frequently and rapidly recover, these patients are also prevented from being admitted to Newark Hospital by ambulance.

 

The Human Argument

If we consider the geographical position of Newark, as shown in the NHS review document, the town is shown at the centre of a map with the hospitals of Lincoln, Mansfield and Nottingham all some 20 miles distance from Newark. Any serious medical cases found within 10 miles of Newark should ideally be treated at a suitably staffed and equipped local hospital.

The NHS Institute for Improvement and Innovation – a national NHS body aiming to improve quality – has argued for many years that commissioning on the basis of averages is erroneous. They advise compiling run charts and using statistical process control (SPC) to determine what is normal variation and what is due to extraneous special causes[3].

The consultation document claims that, on average, less than one patient per hour is seen between 10pm and 6am. By performing the analysis referred to above on the A&E attendance data at Newark from October 2007 to October 2009, it provides a mean of 7 patients per night between 10pm and 6am (or 6 between midnight and 8am), but anything up to 15 patients should be considered within normal variation. So the figures quoted by NHS Nottinghamshire County seem inaccurate.

An examination of the case mix shows that major case patients (those who are more serious and dealt with on the trolley side) the rate is remarkably constant throughout the 24-hour period. For interest, the daily attendances have a mean of 66 per day, but anything up to 95 should be considered normal (figures and graphs are available).

Given the amount of daily variation this means that the future challenge is in managing variation. Thus maintaining a sustainable service over the full 24-hour period is less about the demand and more about workforce planning where there is a large amount of variation, and being able to provide a safe and cost effective service out of hours.

Population Growth

The NHS Review Document reported that so far this year 530 more people than in the same period last year asked their GP to refer them for an appointment at Newark Hospital – a 9% increase in referrals.

The NHS consultation document states that ‘there are about 43,000 people living in Newark’. If we consider those who might use the hospital, the population of Fardon, Balderton and surrounding villages within a ten-mile radius should also be considered ie. half way to other available hospitals such as Nottingham, Lincoln and Mansfield. The population of greater Newark is therefore more in the region of 70,000, not 43,000.

Newark has been granted ‘growth-point-status’ which will see the town expand over the next 20 years. It is expected that between 5,000 and 8,000 or more new homes will be built. This proposal for new housing in Newark is expected to increase the population by at least a further 18,000 by 2030. If the Growth Point predicted figures are added the projected population of greater Newark by 2030 would be 88,000. This figure is more than double the figure stated in the Consultation document.

The Consultation document also states the ‘Newark population could increase by 45% by 2026…and that the number of over 65’s in Newark and Sherwood is expected to double’. This predicted increase in the elderly population, who are by definition in greater and more frequent need of local medical services, strengthens the argument that there needs to be a dedicated ward or new specialist hospital situated in the town to serve the needs of elderly people requiring in-patient care.

Busy Roads and Rail

Newark with its central Midlands location has much passing road and rail traffic. The A1 trunk road is a major thoroughfare for traffic travelling north and south. And the A46 is also a major road with vital links to cities in the region and further afield. The main east-coast rail line carries many thousands of passengers daily. Local roads and rail carry heavy traffic and having a fully staffed and operational emergency care centre at Newark means that a major accident or disaster could be dealt with locally and immediately.

Creating a Super Hospital in Mansfield

King’s Mill Hospital is currently undergoing a radical transformation to create a world-class facility at significant cost. Current estimates indicate that Kings Mill is not attracting sufficient NHS contracts to fund this recent investment. As such, new ways to attract contracts and therefore income have to be created. This is likely to lead to a diversion of services from less high profile hospitals such as Newark.

A Greener Future

The NHS has the largest carbon footprint of all public services.  The NHS Carbon Reduction Strategy for England 2009 states that:

Climate change is one of the greatest threats to out health and well being.  It is already affecting health across the globe.  The NHS as one of the largest employers in the world has an important role to play in reducing carbon emissions, a key cause of climate change.” 

 The East Midlands NHS Sustainable Development Network states one of its aims is to “equip NHS organisations to reduce their carbon footprint whilst improving the quality, productivity and effectiveness of their World Class services

At no point in the Consultation document is reference made to the increased carbon emissions that will result from increased travelling by ambulance, and by private car, by patients being admitted to hospitals remote from Newark, and by relatives visiting. Additionally, the emotional and financial impact on families from increased travel to remote hospital locations is disregarded.

Friary Ward – In-patient Services

There are fears the option for mental health services for older people in Newark are being overlooked. Newark Hospital’s Friary Ward, which cared for older patients with mental health problems, has been closed since December 2009. Friary Ward’s future and related services form part of the Newark Healthcare Review.

The consultation does not address what will happen to in-patient services. A look at what acute patients Newark Hospital does accept show that a significant proportion have an acute illness (such as a chest infection or a urinary tract infection) on top of pre-existing dementia. The acute illness in itself may not necessitate admission, but because of the dementia that person cannot safely be returned home. These patients require a prolonged length of stay but they are not necessarily the kind of patients that you would want occupying beds in larger hospitals. These patients’ best interests would not be served by taking them further away from what is familiar to them. A ten-year strategy needs a thorough investigation of dementia care and particularly relevant to Newark Hospital is how acute illness with dementia as a co-morbidity is handled.

Funding Shortfalls

It was reported that the East Midlands is one of the worst funded regions in the UK (BBC 26th March 2010). The East Midlands Regional Committee found that, according to a parliamentary report, services are suffering because out of date population statistics are being used to allocate government funds. The report found 23 out of 24 PCTs are not receiving their target funding. The East Midlands, it said, has the fastest growing population of any UK region between 2001 and 2007, and the trend is set to continue. East Midlands MPs are now calling for the most current population data to be used for funding calculations. Additionally it is estimated that in the East Midlands there will be a financial shortfall of £0.8 billion.

For the purpose of allocating appropriate local health funding, it therefore seems quite probable that the current population data for Newark and District are outdated and inaccurate, and in addition do not take into account predicted population growth as detailed earlier in this report.

Newark’s Healthcare Needs for the Future

Dr Andrew Parkin is quoted as saying ‘The NHS Review will look at healthcare as a whole and is a once-in-a-lifetime opportunity to provide a blueprint for health services in Newark for the next 50 years’.

A key policy driver is shifting care into the community. Hospital is an expensive resource. Furthermore, a stated aim of the Newark strategy is that care should be provided in the right place first time.

However, the proposed long-term strategy appears to keep the boundaries between primary and secondary care static. There are opportunities in Newark for much greater integrated working between primary, community and secondary care.

As detailed above there is a large amount of variation in demand. The ambulance service may be busy; primary care may be busy; the hospital may be busy. But it rarely works out that all are busy at the same time. If staff worked more flexibly across the organisational boundaries it could create a better model for managing the peaks and troughs in demand. Ambulance and primary care staff could work in the hospital and hospital staff could be deployed into the community. It would help ensure services are sustainable, cost-effective and staff well utilised.

Furthermore technology can also contribute to improved services. There is little mention of tele-medicine within the strategy. Newark Hospital has pioneered the use of point of care blood testing. The lab staff run an office hours service and out-of-hours clinical staff use near patient testing to obtain results themselves. These machines are small and portable – they could potentially be used in ambulances while in attendance at people’s homes. If hospital staff were to take their acute assessment skills together with diagnostics equipment to the place of first contact then the decision whether to admit or not, and if admission is necessary then whether to Newark or a larger centre, could be made before the patient is transported. The right place, first time principle. Once at Newark Hospital, or indeed any primary care centre, then remote tele-medicine links could mean consultations and advice can be obtained without the need to travel.

The traditional model of ambulance, primary and secondary care will err on the side of patients being transported because there is insufficient skill or insufficient information to make the decision to stay local. The traditional model and traditional roles do not support ‘right place, first time’.

Through new roles like the Acute Care Practitioner, Newark has shown itself to be capable of developing innovative and bespoke solutions with safety at its centre. Short-term changes that reduce capability will be much harder to build up again once withdrawn. The strategy could be much more imaginative, yet staff do not appear to have been included in drawing it up.

Finally, there is an opportunity to design a much more flexible structure – along similar lines to the vision Dharzi sets out – which is altogether more radical than what is proposed. This strategy does not look broad enough and needs to include a social determinants approach to health, as outlined in the Marmot Review (www.marmot-review.org.uk). The consultation questions are therefore the wrong ones to be asking.

 Dr Ian Campbell

Chair

25 May 2010

 


[1]  ‘Better Together – Improving Consultation with the Third Sector’, Cabinet Office http://www.google.co.uk/search?hl=en&client=firefoxa&hs=nFe&rls=org.mozilla%3AenUS%3Aofficial&channel=s&q=Better+Together+government+consultation+guidance&aq=f&aqi=&aql=&oq=&gs_rfai=

[2] Department of Health (2008) Treatment of Heart Attach National Guidance, p22 http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_089454.pdf

[3] http://www.institute.nhs.uk/quality_and_service_improvement_tools/quality_and_service_improvement_%20tools/variation_an_overview.html