We welcome the idea of changes that would improve local services; the facilities provided by GPs and at Community Hospitals, more community based nursing, and improved facilities at either Worthing or Chichester, however we believe that the proposals:

· Put at risk the quality of care available in the north of Horsham District

· Fail to address present problems

· Provide insufficient detail to allow an informed decision to be made.

A major review of this type must tackle the major problems. It is unacceptable to propose sweeping changes while leaving fundamental problems unaddressed. The proposals should be withdrawn and a solution that provides a fair and equitable level of care to everyone across West Sussex should be proposed.

The northern part of Horsham District/ Horsham Town/Crawley area is already inadequately served in terms of ready access to:

· An acute hospital

· Maternity facilities

· Accident and emergency facilities

Whether provided in the future at East Surrey, Worthing or Chichester, these facilities would be too far away and too difficult to get to except by car.

All three consultation options will, according to the PCT's own figures significantly increase patient numbers at East Surrey.

· All three options would increase patient numbers by approximately 30% to 33%.1

· Outpatients would increase by 50% if Princess Royal becomes a Community Hospital as in two of the three options. 2

East Surrey already has difficulty coping with patient numbers and A&E waiting times. The trust that runs the hospital has a substantial financial deficit, has had zero ratings for clinical performance and for the last two years its performance has been rated as "weak"; the lowest rating of the four possible ratings; rather than fair, good or excellent.

Patients in the Horsham District are currently treated mainly at East Surrey and Worthing, it is not acceptable to propose changes that will result in:

· Our nearest hospital, East Surrey, a hospital that is well below standard, being over loaded,

· Acute services being moved from Worthing to Chichester, which is considerably further away.

The Chief Executive of the Surrey and Sussex NHS Trust, in a letter to the PCT of 6th June confirmed that East Surrey Hospital could not presently meet the extra volume of either Accident and Emergency or Maternity; "in relation to maternity…the current physical facilities would not be adequate", and with respect to A&E; "similarly we would require capital investment to improve facilities". In addition to capital investment, the three options, all result in further annual expenditure at East Surrey of; £12.6m, £8.2m or £13.1m. 3

If there is to be further expenditure to meet the needs of the people who live within West Sussex then we believe that it should be spent within new facilities, suitably located within West Sussex, and not at a location that is too far away, and too difficult to get to.

None of the hospitals proposed in Fit for the Future as suitable to provide major acute care; Chichester, Worthing, Brighton, East Surrey, is readily accessible by road or rail. They are located in congested urban areas and not accessible from motorways. None of them is centrally located within the areas that they would serve. A plan for the future provision of care cannot be based on hospitals with such inaccessible locations. To be fit for the future hospitals must be located where they can be easily and quickly reached. In West Sussex, where people are located either mainly along the coast or along the A23 corridor, this need cannot be met by a single major acute hospital.

To provide an equitable level of care across the county there needs to be two major acute hospitals in West Sussex:

· One at Worthing or Chichester serving the coastal area and the southern part of the County

· Another, new hospital, connected to the rail network and readily accessed from the M23/A23, in the Horsham/Crawley area, serving Horsham, Crawley and Mid-Sussex.

A new hospital might be funded by PFI or private sector finance with patient revenue from the area it serves. A solution that will be fit for the future cannot be found by seeking a location for just one major acute hospital. To do so renders the exercise worthless since safe and appropriate health care cannot be provided in West Sussex by a single major acute hospital.
A fundamental argument within "Fit for the Future" is that existing local hospitals would be downgraded and an enhanced level of care would be delivered through greatly enhanced primary care facilities. The public cannot be expected to agree to the proposals when there is no commitment within "Fit for the Future" as to the specific improvements that would be made to primary care.

We do not know:

· what additional facilities would be provided within GP surgeries

· where Community Hospitals would be

· whether a Community Hospital would have a minor injuries unit or a better resourced urgent care centre

· the hours during which minor injury units and urgent care centres would be open

· the location and number of midwife run birthing units, although we welcome the suggestion that consideration is being given to having more than one.

· the extent to which community nurses will be available to care for patients who will be cared for in their own homes instead of within hospitals.

In summary we ask that:

· none of the proposed options is adopted until consideration has been given to a solution that fairly and equitably meets the needs of everyone across West Sussex noting the lack of access to services in the north east of the county.

· consideration is given to meeting the need by having two acute hospitals instead of the one proposed; one in the coastal area and one to the north in the Crawley area.

· the adopted strategy increases the flow of investment and expenditure towards facilities within West Sussex and not to facilities outside the county, so that more patients are treated locally.

· the implementation of any strategy is not commenced until there is absolute clarity, and a firm commitment, as to the enhancements that will be made to primary care and the facilities to be provided within Community Hospitals.

· any final decision should wait for Lord Darzi's report on the health service in nine English regions, due in the spring of 2008.

· Sir Graeme Catto in his review of the case for an acute hospital in the NE of the County considers the points that we have made.

There are too many questions that still need answering including precisely what enhanced primary care and Community Hospital facilities would be provided, what A&E and maternity facilities would be available, where they would be and when they would be open. If there must be change and fewer acute hospitals, we believe that the minimum requirement is for:

· a new major acute hospital, probably funded by PFI or private sector finance, northwards away from the coast close to Crawley and with convenient access from the M23 and by bus and rail.

· a major acute hospital serving Brighton/Worthing/Chichester; located at either Worthing or Chichester.

· 24/7 A&E and consultant led maternity units at both major acute hospitals.

· good Community Hospitals serving the main communities; e.g. at Haywards Heath, and Horsham.

Councillor Dr David Holmes
On behalf of The Liberal Democrat Group of Councillors on Horsham District Council
david.holmes@horsham.gov.uk
01403 267712

Notes to figures quoted.
From PCT supporting data sources.
1 East Surrey catchment area is estimated as 310,000 to 350,000. Under option A this increases to 430,000 and under options B and C it increases to 440,000.
2 East Surrey outpatients are currently 15,296/annum and the PCT estimates that this would increase to 21,566 if Princess Royal becomes a community hospital.
3 East Surrey cost is currently £49,127,942. The East Surrey cost for options A, B and C is estimated by the PCT at: £61,705,609, £57,344,228, £62,233,533 respectively.

Appendix

Additional observations on Fit for the Future by the Horsham District Council Liberal Democrat group.

Accessibility
· Worthing and East Surrey are both approximately 40 minutes distant from the north of Horsham District, depending upon traffic, and located within urban areas with the result that congestion can further significantly delay travel times. Chichester is 10 or 15 minutes further.
Distance is a major issue both for the seriously ill patient who might die enroute and for those who are regular visitors, in terms of time, convenience and cost.
None of the three proposals improve the situation. Any major review of how services are delivered in West Sussex must attempt to address this unacceptable situation.

Whether one major hospital is enough
· "Fit for the Future" makes the basic assumption that there can only be one Major General Hospital. The possibility of two Major General Hospitals was only considered in relation to both Worthing and St Richards becoming Major General Hospitals and was rejected on the basis of inadequate catchment areas. The acceptability of the assumption has not been justified, as it should be, in terms of meeting clinical need. Care provision across the UK should be based upon providing a fair and equal service to everyone and not on a philosophy of one Major General Hospital per PCT. The distribution of population within the county, along the southern coastal edge and then up the A23 means that it is impossible to serve the needs of the County with just one major acute hospital.
· It is recognised that a Major General Hospital needs a population of around 300,000 to 350,000; West Sussex has a population of over 750,000 therefore it would be reasonable for it to have two Major General Hospitals. Given that currently a large amount of money flows out of West Sussex following the patient to other hospitals if patients are treated in a new West Sussex hospital much of the required revenue funding would be available.
· The soundness of reducing hospital care to one major hospital in the county is not based on proven medical models but on theory of a few individuals. Indeed the Royal Colleges are not convinced of the argument that concentrating all the expertise in one Major General is the way forward.

Whether the proposed maternity and A&E provision is adequate
· The plan envisages one consultant run maternity unit for the county located at the Major General Hospital and one small midwife led unit somewhere else. It would not be safe to have the midwife led unit remote from the facilities of a hospital with a maternity unit; similarly if there are to be more home births they too need to be in easy reach of a hospital with a maternity unit. It seems impossible to imagine all the births currently dealt with at St Richards, Worthing and Princess Royal being dealt with at one hospital. The practicality of this needs reviewing. Similarly, an Accident and Emergency unit located on the southern coastal edge cannot be described as a "centralised" unit. There should be two consultant run maternity units and two Accident and Emergency units located at two major acute hospitals; one in the coastal region and one northwards close to the A23.

Uncertainty as to availability of services at the Major General Hospital
· It is not clear which facilities would be available 24/7 at the Major General Hospital. On page 10 of the Consultation document it is suggested that at the centres of excellence staff might only be available 18hrs/day.

The need to consider the policy of adjacent PCTs
· An appropriate pattern of hospitals cannot be reached by looking at West Sussex in isolation. Consideration must be given to what is planned in East Sussex, Brighton, Hampshire and in Surrey. If the closure of other hospitals results in more patients using East Surrey then the case for an additional hospital in the Crawley/Horsham growth area becomes more compelling since it would not threaten the viability of East Surrey Hospital. Clearly the situation in Surrey cannot yet be properly considered since so far no proposals for Surrey have been made and consultation has not begun.

The needs of the people of West Sussex should be the first consideration
· Fit for the Future states that the case for a new hospital in the NE of the county has been considered and rejected on the basis that it would destabilize East Surrey Hospital. We feel that this argument is invalid on two counts:
· West Sussex PCT should give precedence to meeting the needs of the patients for which it has a duty of care before considering the financial interests of a neighbouring Hospital Trust.
· West Sussex PCT should note that were it to consider an option that reduced the number of patients from West Sussex travelling to East Surrey adjustments might be made within Surrey that compensated for the loss of patients.

Investment in air ambulances must be allowed for
· Given the greater travel distances for serious acute cases the cost of more air ambulances must allowed for.

Feasibility and credibility of promises made
· Government policy on health care is liable to continuous change. We do not wish to be caught half way with down graded hospitals and no compensating Major General Hospital offering superior care and equally no enhanced primary care. During consultation sessions John Wilderspin, Chief Executive of West Sussex PCT, has confirmed that no downgrading would take place before the service enhancements are in place but we need firm guarantees on this since it is difficult to believe that it would be financially possible to deliver such a promise. We believe that the cost of continuing to run the present system while at the same time providing the enhanced system would be prohibitive.
· Similarly it is suggested that there would be nursing care available within the community 24/7 providing what is termed a "virtual ward". It is not believed that this could be delivered on the grounds of both cost and the availability of nurses.
· In proposing a new way of delivering health care it is inevitable that the advantages will be seen as attractive. The fact that the "distant grass is always seen as greener" is well recognised. The concern is that the disadvantages have not been fully recognised and considered.
· It is of great concern that the Fit for the Future proposals do not seem to have gained community support. For that reason alone it would seem that a rethink is needed. Clinicians have raised major concerns re the proposals and many GPs have not been consulted. The public are demonstrating about the reduction of hospital services and there is no support from the local councils or the WSCC.

The fourth option
There has been talk in the press about a fourth option that would in effect maintain the status quo. Hospitals would remain at Worthing, Chichester and Haywards Heath. They would retain accident and emergency departments but only one of the three hospitals would have a maternity facility. While we appreciate that this is not an option included within the consultation we feel that we should comment on it. If Fit for the Future aims to change how health care is delivered in West Sussex so that its provision in the future is better, safer and fairer for everyone then the fourth option would fail to do so.
· It would not address the poor access to acute hospital facilities in the NE of the county.
· Assuming that, as Fit for the future asserts, improved services at the primary care and Community Hospital level are needed, the fourth option would be hard to justify if its cost meant that the improvements at the local level could not be made.
· Access to maternity facilities would still be inadequate as we consider that hospital based maternity facilities should be conveniently located to both those in the south of the county and those in the north east.