There is no clinical case for retaining the accident and emergency department at Chorley and South Ribble Hospital - because it is no longer viable to provide the service from that location.
That is the conclusion of dozens of medics drafted in to help draw up a shortlist of options for a public consultation into the future of the Euxton Lane site.
Reports by four different sets of clinicians have all come out against the possibility of restoring a round-the-clock A&E unit at the hospital - and neither do they support the facility retaining its current part-time status.
That means the public are likely to be presented with three options - two of which would see the A&E replaced with different versions of an urgent treatment centre (UTC).
However, the option of sticking to the status quo - which has seen the A&E department open for 12 hours a day since January 2017 - is still set to make it to the shortlist, so as to provide a benchmark position against which the proposed alternatives can be judged.
Although not deemed to be clinically viable, the current set-up will have to be considered as an option in its own right - in case the process concludes that one of the other suggestions is found to be unsustainable for a non-clinical reason, such as finance or impact on patient travel times.
Under each of the remaining options due to be recommended for inclusion on the shortlist, a 24-hour UTC would be created. Both of the proposed models would offer an enhanced level of care compared to the existing UTC facilities available at the Chorley site.
In all scenarios, the wider hospital would remain open and would take on a greater volume of pre-planned operations.
A final decision on the shortlist will be made by a joint committee of the Chorley and South Ribble and Greater Preston clinical commissioning groups (CCGs) this spring - with the consultation itself expected to begin over the summer. But whatever that list looks like, it will not prevent the public from making other suggestions.
“If people feel there is an option which should be brought back onto the table or they disagree with [our recommendations] and believe that there’s other evidence - they’re perfectly at liberty to say that,” explained Jason Pawluk, delivery director for the local NHS Our Health Our Care (OHOC) programme.
“They can still put forward their case, their reasons and arguments.”
Last August, OHOC published a so called “long list” of 13 options for the future of the Chorley site - many of which were differentiated by how its non-emergency facilities would be designed.
But the process of whittling down the suggestions stalled after the joint CCG committee concluded that they all needed further assessment by a group of local clinicians and NHS leaders. That work is now complete and the three options to be recommended for the shortlist have been subject to further modelling to show how they would work in practice.
The findings of the clinical groups will be presented to a meeting of Lancashire County Council’s health scrutiny committee next month. The Lancashire Post has seen the 150 pages of documentation which have been submitted.
Although the four groups - two of which were made up of clinicians from outside Lancashire - were not collectively unanimous in their views about the best way forward, they were found to have coalesced around the urgent treatment centre options.
Retention of A&E at the Chorley site was ruled out by the clinicians consulted over the proposals, largely for staffing reasons. A shortage of middle grade doctors led to the complete closure of Chorley A&E for much of 2016 and is the reason which has been cited for its part-time status since reopening exactly three years ago.
OHOC analysis of the recommended shortlist claims that the two suggested UTC options would lead to an increase in the local availability of all grades of hospital-based medic - except junior doctors - across both emergency and medical care. Staff availability in critical care would be largely unchanged.
Once the joint CCG committee has made a final decision on the shortlist options, it will have to submit all of the work which has been done so far to NHS England. If the regulator is satisfied with the approach that has been taken, the full public consultation - which will last a minimum of 12 weeks - can be launched, probably in June.
The Lancashire Post understands that even on the most optimistic timescale, a final decision on the A&E unit following the outcome of that consultation - which will be made by the joint CCG committee after further consultation with the health scrutiny committee - is unlikely to come this year.
Any changes, once they are agreed, would be phased in over a five-year period and completed by 2025.
“We’ve done an awful lot of work listening to the public and now is the right time to progress to a consultation,” Jason Pawluk said.
“There is also an important need for certainty around the direction of travel, so people can understand the potential options and what’s being considered - and they can have their say.”
WHAT’S THE DIFFERENCE?
Out of the two versions of an urgent treatment centre (UTC) recommended for inclusion on the shortlist, the first is known as an “enhanced UTC”. It would be open 24 hours a day, but staffed by an “acute medical senior decision-maker” for half of that time and GP-led during evenings and overnight. There would also be an ambulatory care unit focused on treating patients without the need for them to be admitted.
The second UTC option would also be a round-the-clock facility, but staffed by GPs only. It would treat a slightly wider range of minor injuries and ailments than the existing UTC at Chorley.
Under both options, Chorley would lose its critical care unit, which the NHS North West Clinical Senate says is one of the most under-utilised such facilities in the country. The Royal Preston is currently extending its critical care facilities and is also the region's major trauma centre.
The Chorley site would instead become the focus for routine, pre-planned surgery in Central Lancashire - providing an enhanced care unit for post-op recovery.
According to Jason Pawluk, delivery director for the Our Health Our Care programme, the facility would be classed as a “centre of excellence”.
“The rationale is to maximise the available utilisation of the trust’s theatres, its beds and critical care facilities. The view is that by [converting] Chorley into an elective centre and making Preston more of a medical centre, you’d be allowing the trust to manage overall activity better.
“That would improve elective times by reducing cancellations, improving access and patient experience.”
Mr. Pawluk also said that the potential changes would cause only “a small proportion of patients” to travel further than they do now for treatment.
“Just looking just at urgent and emergency care, 89 percent of patients would still be able to get their care at Chorley [under the enhanced UTC option], so only 11 percent would be affected. That figure is slightly lower for the GP-led UTC service at 84 percent.
“Looking at all emergency and elective patents together, 96 percent would either be the same or better off [in terms of distance travelled for treatment].
MPs UNITE TO SAVE A&E
Chorley MP Sir Lindsay Hoyle - a longstanding critic of Lancashire Teaching Hospitals (LTH), which runs Chorley and South Ribble Hospital - has called for the trust to hand it over to a neighbouring NHS organisation.
“Why do we have to have Lancashire Teaching Hospitals running it when they can’t deliver and haven’t got the competence to recruit?
“If they can’t do it, then why not bring in a neighbouring trust like Wigan, Bolton or Blackburn?
“LTH are failing the people of Chorley and South Ribble, so we should have the ability to look elsewhere for someone to run our services.
"You can’t have an area like this, with the biggest population growth in the North West, and not retain your [A&E] services - that would be folly. So all options should be on the table and not just options that are geared towards the trust’s wishes and desires.
"The least I’m settling for at this stage is no removal of 12 hours [opening], but I want to enhance it to a 24-hour service and am working with other local MPs to achieve that," Sir Lindsay added.
Those fellow parliamentarians include Ribble Valley MP Nigel Evans and recently-elected South Ribble MP, Katherine Fletcher.
"I’m a new MP and Sir Lindsay has just started a new job [as Speaker of the Commons], but we've both made sure that we’ve met to discuss this - because it's vitally important,” Ms. Fletcher said.
"We both agree that the A&E should be restored to 24-hour operation as soon as possible. It’s a valued service and there is the money to pay for it.
"It’s not a lack of funding that is preventing that department being open 24 hours. It’s down to operational issues around recruitment - and they need sorting.
"I’m speaking with the trust and they’re giving me a detailed brief on what’s there at the moment and what they want to be there - I’ll be reading that along with all the other documentation that has now been published."
In a statement, LTH chief executive Karen Partington said: “The three separate reviews involved each clinical body visiting central Lancashire to speak to dozens of staff at both hospitals, who offered their own experiences and opinions around working at both sites, backed up by the clinical data they provided.
"We will continue to work with all of our partners through the OHOC programme to assess all of the options for change, with the ultimate aim of making sure our hard working, dedicated staff are able to use their skills to best effect and provide the highest possible standards of care for local people.”
WHAT THE REPORTS RECOMMEND - AND REVEAL
Four groups of clinicians were commissioned to assess the 13 options put forward last year for the future of Chorley and South Ribble Hospital.
The partial findings from one of them, the Royal College of Emergency Medicine (RCEM), were published in part back in August. But their full report reveals the scale of the challenge that they believe is facing the NHS in Central Lancashire.
While the medics agreed that consolidation of emergency services onto a single site in Preston would ease staffing pressures, they warned that the move would lead to “longer travel times for some patients, with uncertain impact on a small proportion with high acuity problems”.
The RCEM report also described the current Chorley A&E as “a safety valve” for the Royal Preston.
“The Preston site would struggle to cope with the workload were emergency medicine and acute/general medicine services to be moved to that site. This is because of the quality and configuration of the estate and the current difficulties with patient flow,” it said.
The medics also said that staff had told them during a visit last April that they felt that “they have been asked to adopt a current model with which they do not feel comfortable, at least partly as a result of political and public reactions to a previous downgrading of the emergency department] at Chorley”.
Meanwhile, an NHS North West Clinical Senate report acknowledges “the commitment and dedication of staff” for keeping the current arrangements sustainable for as long as they have been and for innovations in working across the two sites..
“Staff are providing excellent services - and this is a credit to them,” the senate report states.
All of the reports express varying levels of concern that local NHS leaders are placing too much faith in the capacity of ongoing moves to expand primary care and community services to be able to alleviate the strain being felt by hospitals. RCEM describe the hope that it can help manage demand as “wishful thinking”.
The government’s recent promise of “seed funding” to help draw up a business case for a new single-site hospital in Central Lancashire was also dismissed as being too distant a prospect to justifying pausing the more immediate plans for an overhaul of NHS services in the region. A local clinical oversight group ranked it as one of their most-preferred options, but several members acknowledged that any new build facility - should it materialise - is expected to be at least a decade away.
The Royal College of Emergency Medicine (RCEM) visited Central Lancashire last April. The registered charity - which sets training and examination standards for emergency medics - sent a four-strong team for a two-day review of the current system and assessed future proposals for urgent and emergency care in the region in light of what they saw.
The Lancashire and South Cumbria Care Professionals Board - made up of medics from across the patch - visited in July.
They were followed in September by the North West Clinical Senate - a group of clinicians from across the North who made the trip to Central Lancashire to examine the long list of options for the future of urgent and emergency care. Their report is part of the "assurance process" which will determine whether or not NHS England gives the green light to a full public consultation on the proposals.
Finally, an strengthened local Clinical Oversight Group held a summit in Farington in October, during which 25 health and care professionals scrutinised the 13 options for NHS services in the area.