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THE PEOPLE’S OPTION ON THE FUTURE OF WEST CORNWALL HOSPITAL

Prepared by West Cornwall HealthWatch March 2001

Section 1	STATEMENT BY
Section 2	IN THE BEGINNING …
Section 3	THE PEOPLE’S OPTION
Section 4	WHAT THE PEOPLE OF WEST CORNWALL WERE PROMISED IN THE NHS PLAN
Section 5	WHY WE BELIEVE THAT WEST CORNWALL IS UNIQUE
Section 6	UNDERLYING FACTORS
Section 7	CASE HISTORIES & CONCLUSIONS
Section 8	CENTRALISATION AND ITS CONCERNS
Section 9	A POSTCODE LOTTERY ?
Section 10	SUMMARY
Section 11	ACKNOWLEDGEMENTS AND LETTERS OF SUPPORT

Section 1

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STATEMENT BY

The Government originally stated that its top priority was
education – education – education.

The result of a national survey into the key
concerns of the British Public, announced in early December 2000, showed that
42% mentioned Health as their top priority
and only 27% mentioned education.

Without a first class truly NATIONAL health service, then public monies put into the education of the country and job creation will be of no avail.

If people do not have the provision of
quality health care they cannot take full
advantage of what life has to offer.

It is this committee's view that the top priority of
the Government has to be
HEALTH – HEALTH – HEALTH

Section 2

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IN THE BEGINNING …

In recent years +has become increasingly concerned about the way in which the provision of health care in West Cornwall is being planned and implemented. It was because of this, became involved, and played a major rôle in saving our community hospitals and services at West Cornwall Hospital more than three years ago.

More recently we have welcomed the opportunity to take part in, what appeared to be, the drawing up of a comprehensive, bottom-up Health Improvement Plan for our area. However, it became clear that not only were we, the general public, not being involved in future plans, but late in 2000 we learned that there were plans afoot for a 'clinically led' review with regard to the future rôle of West Cornwall Hospital.

Therefore, at the request of the local MP, Andrew George, we called a Public Meeting at the Queens Hotel Penzance on Tuesday 10th October 2000. Despite bad weather, over 300 people attended, indicating the level of concern felt about this matter.

On the platform were: Jack Aitken, Mayor of Penzance; Marna Blundy, Co-ordinator of ; Peter Cox, Clinical Director of, and Consultant Surgeon at West Cornwall Hospital; Rosemary Harker, GP; Malcolm Jones, GP and Chairman of the West of Cornwall Primary Care Group; David Levine, Consultant Physician at West Cornwall Hospital; Rob Pitcher, Assistant Medical Director of the Royal Cornwall Hospitals Trust; Neil Walden, GP and Glyn White, Chairman of the League of Friends of West Cornwall Hospital.

The key points we heard that night were:

· That local Consultants and GP's were being "open, honest and brave" to highlight the need to change and improve local Clinical Care. Malcolm Jones

felt that no evidence had been presented to show that the changes, whatever they were, would improve clinical care.

· "Your best chance, in cases which are complicated or unpredictable, is by going to a larger hospital with a much bigger range of Specialists" David Levine

No evidence was presented to support that statement and indeed we have since learned that medical opinion is divided on this issue.

· "If medical emergency admissions are stopped at West Cornwall Hospital, then surgical emergency admissions will have to go too." Peter Cox

Due to the common support services that are required by both medical and surgical teams, if we lose one, we lose both. The resulting domino effect would bring about the end of West Cornwall Hospital as we know it.

· “We couldn't find a Cardiologist with the right skills who would work here" David Levine

We understand that the post was never advertised. Not surprising therefore, that no one applied!

· "This isn't about planning health services behind closed doors and coming up with a plan that is presented to you the people once it's formulated giving you no opportunity to amend or alter that plan". Malcolm Jones

To date, the ordinary person in the street has not seen any options. We fear that at the end of the day we will be faced, not with a choice - but a conclusion.

· "Medicine's changed so much over the years that we cannot sensibly carry on admitting all the usual medical emergencies to West Cornwall Hospital."

· "West Cornwall Hospital simply cannot offer the right facilities for many emergencies which would be life threatening."

· "West Cornwall Hospital services have not, as has been reported, been steadily eroded" David Levine

More services have been taken away from our Hospital than have been given, and that by any standards is erosion. The implication of the first two statements is that MORE will be taken away in future, and that West Cornwall Hospital will become a 9.00 to 5.00 hospital.

The following is just one of the statements made that night by a medical practitioner.

· "…. we have real concerns about the plans that are being thought about and the fact that these plans are being rushed and not properly thought through. We know that Treliske is under pressure and cannot at present cope with all emergencies.

For example, if you have a heart attack you should see a Cardiologist. Current waiting times in Cornwall to see a Cardiologist are 35 to 93 weeks, this is just not a practical option." Rosemary Harker

This statement gives an insight into the fact that not all of the medical profession is happy with some of the possible changes.

· "We are absolutely committed to consider all the options" Malcolm Jones

Our question becomes repetitive. What options?

· "First of all let's just be clear about what I said, a range of medical emergencies would be better treated somewhere else" David Levine

This is yet another statement made by a senior member of the medical profession which highlights that they may be clear about what THEY WANT, but that is not necessarily what WE NEED!

raised five key points through their Co-ordinator:-

	*"Where was the evidence that patients will do better if they go to Treliske instead of West Cornwall Hospital?"*
	*"How can we be assured that Treliske would be able to cope with all emergencies?"*
	*"What about other options for the future, besides that statement that we cannot apparently keep what we currently have?"*
	*"How are we all supposed to get up to Treliske and how many more ambulances will it take to get us there?"*
	“David Levine said, ‘We are living on a legacy of a mistake that was made all those years ago, where Cornwall should have more than one major hospital.’

What I would like to know is why on earth do we have to carry on perpetuating a mistake? When is someone going to have the courage to put it right? "Marna Blundy

None of these five points were answered in any detail!

In July 1999, a paper was prepared by the Joint Consultants’ Committee about the role of hospitals. This document referred to the threat to alter, downgrade or close a hospital or deprive it of any of the services that it had customarily provided, as being a politically sensitive matter that evokes strong public reaction, namely:

"Attempts to change the function of a hospital therefore need to be handled with care and will probably be more easily accepted by the public IF THEY ARE PRESENTED FOR CLINICAL REASONS (our capital letters) by or with clinicians taking a lead in the public consultation process"

The following is an extract from a letter signed by Professor Sir George Alberti, President of the Royal College of Physicians dated 31st July 2000 and sent to Dr David Levine, Consultant at West Cornwall Hospital:

"Thank you for your letter of 17 July . . . .Based on what you have written I agree with you that it will be very difficult to sustain acute medicine safely at West Cornwall … In the meantime you might consider asking the Trust to ask the College Review Team to come to look at Acute Medicine in West Cornwall … A report from us might then take the pressure off the local doctors"

In a nutshell, the above two extracts recommend:

· If as a medical practitioner you feel that changes are necessary, present

them as being clinically led.

This is exactly what happened in the case of WCH!

· Ask a team of more senior practitioners to come down, knowing that the

outcome will be in your favour.

This is exactly what happened in the case of WCH!

Therefore we begin to see that whatever changes are being proposed will be changes that the health service personnel feel THEY WANT and not necessarily those that meet THE NEEDS OF THE PUBLIC.

In the light of the foregoing, decided that as the public had made its views quite clear and had clearly identified THEIR NEEDS, we, as an elected committee, and representing the views of the public, would collate them into this document.

Section 3

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THE PEOPLE’S OPTION

A FULLY MANNED 24 HOUR ACCIDENT & EMERGENCY DEPARTMENT.

"We will create a new Modernisation Agency to help local clinicians and managers redesign local services around the needs and convenience of the patients." NHS Plan page 60 6.15

24 HOUR MEDICAL AND SURGICAL EMERGENCY ADMISSIONS UNDER THE CARE OF CONSULTANTS AND APPROPRIATE JUNIOR/TRUST DOCTOR COVER.

"The NHS has been too slow to change its ways of working to meet the modern patient expectations for fast, convenient, 24hr, personalised care." NHS Plan page 26 2.11

A WIDER RANGE OF VISITING SPECIALISTS FOR OUTPATIENT AND IN-PATIENT TREATMENTS, PARTICULARLY PAEDIATRICS.

"No injustice is greater than the inequalities in health which scar our nation." NHS Plan page 106 13.1

INCREASED DIAGNOSTIC TESTS AND THERAPIES WITH SUFFICIENT BACK UP RESOURCES SUCH AS, A CT SCANNER, ACCESS TO 24HR RADIOLOGY OPINION AND IMPROVED LABORATORY FACILITIES, PLUS MANY OTHERS THAT COULD/SHOULD BE CONSIDERED.

"Patients should have fair access and high standards of care wherever they live." NHS Plan page 58 6.10

IMPROVED USAGE OF THE MORTUARY FACILITIES FOR POST-MORTEMS

(a stressful and costly occasion for relatives without the added need for transfer to Truro and back).

"People are concerned that too much of what the NHS does is dictated by the needs of the system rather than the needs of the patient.” NHS Plan page135 A1.6

GUARANTEED, PUNCTUAL, APPROPRIATE TRANSFER OF PATIENTS TO A MORE APPROPRIATE CENTRE WHEN REQUIRED.

"Services will be available when people require them, tailored to their individual needs." [Introduction by Alan Milburn, Secretary of State for Health] NHS Plan page 15

A GROWTH IN THE SERVICES OFFERED BY WEST CORNWALL HOSPITAL MAY NECESSITATE A PHYSICAL EXPANSION OF PREMISES.

"The decline in the condition of the NHS estate has been halted. The biggest ever hospital building programme is underway." NHS Plan page 1 1.24

The NHS Plan states " The NHS must also be responsive to the needs of different populations in the devolved nations and throughout the regions and localities". NHS Plan page 4.4

ONLY BY IMPLEMENTING THE ABOVE IN FULL, WILL THE NATIONAL PLAN FOR THE NHS BE ACHIEVED IN WEST CORNWALL BRINGING US, AT LONG LAST, INTO LINE WITH THE REST OF THE COUNTRY.

Section 4

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WHAT THE PEOPLE OF WEST CORNWALL WERE PROMISED IN THE NHS PLAN

In his foreword to the NHS Plan, presented to Parliament in July 2000, the Prime Minister personally wrote the following key message:

"It is in a very real sense our chance to prove to my generation and that of my children that a universal public service can deliver what the people expect in today's world. For all of us it is a challenge. But it is one we intend to meet."

identified the following key promises, made to the people of Britain, which specifically relate to the needs of West Cornwall.

· The NHS will respect the confidentiality of individual patients and provide open access to information about services, treatment and performance. page 5.10

· It (the NHS) has over-centralisation and disempowered patients. page 10

· At its heart the problem for today's NHS is that it is not sufficiently designed around the convenience and concerns of the patient. page 15

· Each year patients will see a new NHS unfolding, growing better, more convenient with less waiting times for themselves and their families. page 16

· The vision of this NHS Plan is to offer people fast convenient care delivered to a consistently high standard. Services will be available when people require them, tailored to their individual needs. page 17 1.1

· The decline in the condition of the NHS estate has been halted. The biggest ever hospital building programme is under way. page 21 1.24

Among the improvements the public wanted to see were:

· Better local services - improvements in local hospitals and surgeries. page 25

· Ending the postcode lottery - high quality treatment wherever people lived. p 25

· Near universal support for development of "care closer to home". page 42 4.4

Following its own investigations into the pattern of care the public expected, this was the top-listed conclusion in the NHS Plan.

· Over £300 million will be invested nationally in equipment by 2004.page 45 4.13

· Patients should have fair access and high standards of care wherever they live. page 58 6.10

· We will create a new Modernisation Agency to help local clinicians and managers redesign local services around the needs and convenience of the patients. page 60 6.5

· No injustice is greater than the inequalities in health which scar our nation page 106 13.1

· "The inverse care law", where communities in greatest need are least likely to receive the health services that they require, still applies to many parts of the country. page 107 13.8

· By 2001 local NHS action on tackling health inequalities and ensuring equitable access to healthcare will for the first time be measured and managed through the NHS Performance Assessment Framework. The NHS will need to address local inequalities including issues such as access to services for black and ethnic minorities. page 108 13.13

· People are concerned that too much of what the NHS does is dictated by the needs of the system rather than the needs of the patient. page 134 A1.5

· There is major public concern about variations in services. There is frustration that one part of the country can offer an excellent service, while a neighbouring area struggles to meet basic needs. People want the NHS to be a truly national service, providing high quality treatment wherever they live. page 136 A1.10

	The question on our lips is, ‘Will West Cornwall get its fair share?’
	>every single one of these key promises, needed to correct the unequal provision of Health Care in West Cornwall, is one which all the people of West Cornwall are eagerly waiting to see met.

Section 5

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WHY WE BELIEVE THAT WEST CORNWALL IS UNIQUE

After the 1991 census the Office of National Statistics categorised all areas as urban or rural. Cornwall came out as ‘the most rural single area in the whole of the country’.

There are ample statistics indicating that Cornwall is a deprived area and that West Cornwall is significantly worse off than other areas of Cornwall.

In particular, has discovered that in our area we have:-

	more people per hectare
	more unemployed
	more social housing
	more illness
	more pensioners
	more single-parent families
	and despite its rurality, Penwith alone has more households with no car than other parts of Cornwall. Yet one third of projected new Cornish housing will be in Penwith & Kerrier

· .

In addition we find that:-

	6 of the 10 electoral wards in Cornwall with the lowest earnings are in Penwith and Kerrier.
	More than 40 hours per week for low pay is common in a relatively high proportion of households in West Cornwall.
	8 out of the 10 poorest electoral wards in the whole of Cornwall are in our area.
	In the poorest 4 of these wards more than a quarter of households live in poverty.
	Statisticians reliably inform us that this picture is not expected to change for the better in the 2001 census.
	In January 2001 the Office of National Statistics stated, ‘The gap between the top 10% and the bottom 10% in Britain is still widening’.
	All the facts show that those with disadvantaged status; including inadequate housing, unemployment and existing health problems … all create a greater need for the provision of quality health care in West Cornwall.

Tony Blair tells us in the foreword to the NHS Plan that, “… a universal public service CAN deliver what the people expect in today’s world.”

In West Cornwall this is a challenge which we look forward to being met!

The impact of tourism on West Cornwall

Cornwall is one of the most popular tourist venues in the British Isles with some 3.5 million visitors each year. These welcome annual visitors impose great stress on the local infrastructure. We frequently hear about the traffic problems in the summer, but much less frequently do we hear about the demands these people place upon the Health Service.

Recent figures show that in Penwith at the peak of the tourist season, for every 100 residents there were an additional 73 holidaymakers living here. Add this to the 31 visitors for every 100 Kerrier residents and we have a total increase in the resident population of West Cornwall of over 50%.

Throughout the whole year West Cornwall had over one million resident visitors, six times the resident population. (Each stayed, on average, for six days.)

This does not include the large number of day tourists from other parts of Cornwall, who contributed to the total of over one million extra cars visiting us in the year.

34% of all the houses in Penwith are not main residences, i.e. they are holiday lets and/or second homes. Just like the day visitors, the B & B and those in self-catering accommodation, these temporary residents are not included in the total population of West Cornwall, the population for whom our Health Service is designed.

Add to this the facts that in the Penwith and Kerrier area we have:

	· Newlyn, which is a Port of Refuge
	· A busy fishing port at Newlyn
	· A ferry terminal at Penzance
	· A heliport at Penzance
	· A dry-dock at Penzance
	· An airport at Land’s End
	· An active rock-climbing club
	· Five lifeboat stations
	· Many Clubs and individuals engaged in sailing, sufing, etc.
	· Increasingly, Mount’s Bay could become a cruise ship stop-over
	· A proposed future marina in Penzance
	· A proposed future marina in Hayle

Each of these presents a potentially high risk situation.

argues for the provision of quality health care in this area to take care of both its resident population of 151,000, plus its soaring summer population of over one million day and long-stay visitors. This provision MUST also take into account the high risk factors listed above.

A colourful brochure promoting the attraction of Cornwall for nurses and midwives has been produced (Feb. 2000) by the Royal Cornwall Hospitals Trust.

This brochure bills Cornwall as

“one of Europe’s most exciting playgrounds”.

We don’t think that will be the attitude of those who have the misfortune to be taken ill in West Cornwall

Section 6

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Underlying Factors

LOCATION

Affecting all other considerations are those factors which make Cornwall so attractive to many, the location and topography of the land.

Quality health care provision needs to reflect the underlying settlement pattern and infrastructure of the area. It is easy to see that service arrangements appropriate to, say, London or Birmingham would not be appropriate in Cornwall. But the precise differences in the structure of the communities in Cornwall, which differs significantly from, not just the big cities but those in most parts of England, seems to have escaped the attention of the Health Service planners in the second half of the 20^th century.

In much of England the Saxon and Norman invaders created a settlement pattern consisting of busy central trading hubs, surrounded by satellite villages. These villages depended on the trading centres for their existence. Over the centuries the transport infrastructure evolved to service this dependency.

	This was not so in Cornwall, in part because of our extreme peninsularity.
	The 19^th century pattern of health care provision in Cornwall, with numerous small hospitals, reflected these facts and placed appropriate services within reach of all. Today we find that the Health Service in Cornwall is in conflict with the existing settlement pattern.

SOCIAL EXCLUSION

Social Exclusion occurs when those who need health care are disadvantaged because of the cost of the service, or the cost of obtaining the service; inability or unwillingness to travel out of their home area; personal background; (lack of) education; (previous) experiences; etc.

One of the reasons for the increase in missed appointments could be due to patient’s inability to travel, or the inconvenience of travelling to a distant hospital. If this then results in expressions of disapproval it could fuel a further disinclination in the patient.

One result of social exclusion could be the further deterioration in health of the individual, resulting in an even greater cost to the Health Service than might otherwise have been the case.

These people are not able to take advantage of the opportunities which the present government says should be available to all in society. There is no doubt whatsoever that many residents in the area fall into this category.

SUSTAINABILITY

Sustainability reflects the desire to carry on improving the quality of human life whilst living within the capacity of the supporting ecosystems. In other words, a need to be doing things now which do not prejudice the opportunities of people in the future.

Broad agreement was reached on this topic between the countries of the world at the Rio Earth Summit in 1992.

	Let’s not overlook that this agreement for action included Cornwall.
	is pleased to note that sustainability has not been overlooked in the Rural White Paper (Nov. 2000) which has been embraced by Cornwall Council. “Bringing the Service closer to the People” is a key statement in this document.

One consultant team in Treliske seeing 30 people in one day from West Cornwall is overseeing the potential use of 30 cars travelling a total of 1,560 miles, which would take up 10% of the public ‘Pay and Display’ parking spaces at the Royal Cornwall Hospital.

If that same consultant team had a clinic in West Cornwall Hospital, only one car journey would be required that day. The team from Treliske would be required to make a 52 mile round trip to Penzance.

This case neatly encapsulates the need not only to reduce fuel energy and traffic levels, but the corresponding saving in human energy and stress.

Section 7

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CASE HISTORIES

To put visits to Treliske from West Cornwall into perspective … let us consider four people making arrangements to travel from home (West Cornwall) to Truro (Treliske).

No. 1 A fit and able pensioner from Marazion, married 52 years, wishes to be at her husband’s bedside in Treliske where he will be for the next 10 to 14 days. They’ve always lived very close, inter-dependent lives, so it is only natural that she would want to be with him daily during visiting hours which are from 2.30 pm to 8.00 pm.

The bus from Marazion leaves at	11.42 am
The connection from Penzance gets to Treliske at	1.58 pm
The most convenient return bus leaves at	7.28 pm
Arrival time back in Marazion	9.22 pm
The cost by Senior Return	£4.50. = £31.50 per week
Travelling time	4 hours, 30 mins.
Time away from home	10 hours

No. 2 An eight year old child is in Treliske. Her father is a herdsman in Zennor where they live. Her mother works as a classroom assistant in a school four miles away and travels to work daily with one of the teachers. One or other of the parents must visit their daughter every day. They have no car.

The ‘duty’ parent catches the bus from Zennor at	10.42 am
The connection from Penzance gets to Treliske at	1.58 pm.
The last possible bus leaves Treliske at	7.58 pm
Arrival time in St. Ives	10.02 pm
(this includes a 45 minute wait for a change of bus en route)
A taxi from St. Ives would get them home in 15 minutes	10.17 pm
Alternatively they could walk which would take over one hour.
Cost:return fare £6.70 + taxi £6	Total £12.70 = £89 per week
Travelling time 6 hours
Time away from home 11 hours 45 minutes

No. 3 A young man works in the pub and does odd jobs in Sennen Cove. His wife is in Treliske hospital and his six year old daughter is at Sennen Primary School. Family bonding is vitally important to this young family. He has the stress of fending for himself, caring for the child and visiting his wife as often as possible (a whole day outing), all on a low budget. These worries are reflected onto the wife (who has a lot of time for reflection). The six year old has never been without her mother before. This typical family needs every penny the father can earn.

He is torn between his daughter missing school and missing her mother.

He decides they both shall go to Treliske, but there is no convenient bus out of the Cove in the morning.

Take a taxi to the First & Last Inn at Sennen	10.00 am
Bus from the First & Last	10.23 am
The connection from Penzance gets to Treliske at	1.58 pm
A convenient return bus leaves Treliske at	3.40 pm
After changing buses they are back in the Cove at	6.34 pm
(In making the difficult decision to leave the hospital early and forego 4 hours of visiting, both parents know that the six year old gets home at a reasonable hour.)
Cost: adult return £7.50 + child £6.20 + taxi £5 = £18.70 = £130.90 per week
Travelling time	7 hours
Time away from home	8 hours 40 minutes

No. 4 A lady from Mousehole spent 15 days in Treliske.

Her husband drove himself the 60 mile round journey to visit her each day.

Cost: 60 miles x 15 days x 35p per mile + parking at Treliske @ 60p per visit

Total for the duration of her stay in hospital = £324.

	It has been shown that many low wage-earners in Penwith can only afford to run a car to enable them to get to their place of work. The extra expense, in No. 4 above, would be prohibitive to many. That factor, plus the additional stress on the family and the extended use of the car on already congested roads does not equate with anyone’s concept of sustainability.
	The social and economic consequences upon the health and well-being of patients and their families, the additional potential costs to the Health Service and the cumulative damaging effects upon the environment all add up to a serious indictment of the existing provision of health care in West Cornwall.

CONCLUSIONS

	West Cornwall has more than its share of inadequate housing, unemployment, people of disadvantaged social status, people with existing health problems … all creating a greater, not lesser need for the provision of quality health care.
	West Cornwall residents argue for the provision of quality health care not only for its resident population of 151,000, but for a transient population which multiplies to 23 times that static figure.
	West Cornwall argues for the provision of quality health care which complements, rather than conflicts with the existing settlement pattern.
	West Cornwall is remote from Treliske. The people of this area deserve the provision of a quality health care service for the 21^st century.
	West Cornwall wants to be included in the national programme for the social inclusion of its people and to be actively involved in the sustainability of the future of the human race.

Recognition of the unique status of West Cornwall is acknowledged, indirectly, in the following problem which has been addressed in the NHS Plan

· “… over centralisation and disempowered patients.” page 10 .4

Further acknowledgement is found in these statements taken from the Joint Consultants Committee paper, July ’99

· “… It is important to retain flexibility in local service provision in order to reflect the specific geography, the catchment population and special circumstances and skills that exist, as long as the principles required for best patient care are maintained." page 4 1.4

· “It is recognised that in certain, less populated areas, the continuation of hospitals which cannot meet the recommendations (will be needed) and which may need to be staffed in an exceptional manner.” page 10 5.6

· “In certain geographically remote areas there may remain the need for small District General Hospitals … it is important that all the core acute services are provided.”page 13 7.5

In accepting the rural nature of our area, West Cornwall HealthWatchcalls for exceptional consideration as outlined in the Rural White Paper of Nov. 2000.

Section 8

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CENTRALISATION AND ITS CONCERNS

A paper was prepared by the Joint Consultants’ Committee in July 1999, entitled ‘Organisation of Acute General Hospital Services’. The aim of their document is to record developments in hospital practice, in order to assist (our italics) those involved in planning acute services in the NHS to provide high quality patient care.

It is vital that this point be emphasised. This paper is about how senior medical practitioners would like to see NHS hospitals structured. We labour this point because as this section will seek to show, the advice proffered has been taken by some as to be ‘the gospel writ in tablets of stone’.

The main thrust of their argument is that in order to provide the necessary support both in equipment and staff, the ideal size for a hospital is one that serves a population of 450,000 - 500,000. Hospitals covering this ideal population size would be able to provide the necessary workload for at least two Consultants to cover each speciality. Additionally it would provide the necessary concentrated caseloads, in each speciality and sub-speciality, which are more suitable to the training of Junior Doctors, and indeed enable Consultants to continue to maintain their high professional skills.

The rationale is to be applauded. We all want more highly trained Junior Doctors and we all want our Consultants to continue to hone their skills. BUT, the flaw in the view they put forward is that the development of bigger hospitals does not necessarily lead to their aims being achieved.

	This is not just our view. It is actually a view put forward throughout the above paper. In this respect the Joint Consultants Committee paper is written in a balanced form and with that we have no argument.
	However, it is a fact that the 'other' side of the paper seems to have been overlooked by many NHS planners and medical staff alike.
	We would now like to address this imbalance.

In the foreword, written by J N Johnson, Chairman of the Joint Consultants’ Committee, he states, "This document sets out the views of the Joint Consultants’ Committee on the controversial subject of hospital configuration. It recognises the enormous pressures on small units as a result of reduced doctors' hours of work and lack of continuity of care which accompanies this and of the difficulties caused by increasing sub-specialisation of Consultants particularly in providing 24 hour cover for specialities with larger emergency intakes. Indeed this report must raise the question of whether sub-specialisation has already gone further than is good for the speciality as a whole." (our italics)

The Joint Consultants’ Committee paper raises the following interesting points:

· "It is recognised that it is important to retain flexibility in local service provision in order to reflect the specific geography, the catchment population and special circumstances and skills as long as the principles required for best patient care are maintained." page 4 1.4

argues that the upgrading of West Cornwall Hospital will ensure that this very point is met in full.

· "However there still exists a need for Consultants to practise as generalists with a breadth of skills to manage the range of clinical requirements of emergency patients who often present with a multiplicity of problems." page 5 3.1

This is what we have at West Cornwall Hospital today. Why therefore is it proposed that this be taken away from us?

· “Some 70%-80% of medical admissions and 50% of general surgical, gynaecological and trauma admissions are emergencies and 25% of attenders at A&E are children. All require initial diagnosis and management from a Consultant team with general skills and only a few (our italics) need truly specialist care at the time of admission" page 5 3.4

Again the need for keeping general Consultants, as we have at West Cornwall Hospital, is well and truly borne out by the statistics.

· “Evidence is emerging from volume quality relationships that improved clinical outcomes can be achieved for some treatments by concentrating activity into specialist centres, although some of the published evidence to date is conflicting." (our italics) page 7 3.8

We said it was a fair report and it is, as the above highlights show. However it is the fact that this side of the argument is not being aired, which gives rise to our concerns.

· "It is recognised that in certain of the less populated areas of England & Wales access to secondary care will dominate planning discussions and necessitate the continuation of hospitals which cannot meet these recommendations and which may need to be staffed in an exceptional manner." page 10 5.6

If the residents of West Cornwall do not fit this bill, we would like to know which part of the country does! We therefore submit that West Cornwall Hospital be staffed in this "exceptional manner".

· "Large hospitals would nevertheless present the acute medical units with a very large emergency workload and would create a hospital with large departments that might prove challenging to manage clinically and of a total size that would demand general, executive and management skills and professional co-operation of a very high order for smooth functioning to be maintained." page 12 7.2

Certainly this is proving to be all too true. Derriford and Treliske are prime examples that big is neither beautiful, nor effective, nor efficient.

· "In certain geographically remote parts of England and Wales there may remain the need for small District General Hospitals serving catchment populations of 200,000 or less. It is important that all the core acute services are provided, although the staffing arrangements may make this difficult." page 13 7.5

West Cornwall Hospital serves a population of 151,000, which, at the height of the tourist season soars to many times that figure. We wonder why the Royal College of Physicians Review Body conveniently forgot this fact, put forward by the Joint Consultants’ Committee?

· "When some of the clinical arrangements have been agreed in principle, full public consultation could take place with clinical justification for the changes dominating the argument. . . " page 15 8.4

	The Joint Consultants’ Committee is saying that AFTER changes have been agreed in principle, they MIGHT decide to tell the public. If so the argument would centre around the clinical reasons for the change.
	*There is not one single word about identifying the needs of the area and seeing how these could best be met!*

· "Although the published evidence for improved outcomes is scant, the arrangements for specialisation, notably in paediatrics and surgery and the working arrangements of trainees, suggest that the most cost effective size necessary to meet the requirements for high quality clinical care and pressures for change not least in the respect of training, would be an organisational unit serving a population of 450,000 - 500,000." page 16 9.2

	*The on-going drive by professional bodies to specialise in larger hospitals has not been shown to increase the case-load success rate.*
	We are told that the key reasons for specialisation in larger hospitals are that it is more cost effective and provides a better service. So far these points have NOT been proven.
	*FOR WHOM is this a better service, the providers or the users?*

· In referring to the Smaller and Isolated District General Hospital (serving populations of less than 200,000) the following statements are made

"The training potential of small hospitals in both basic and early 'general' years of higher specialist training should be recognised in all clinical specialities. The benefit to the hospital lies in the stimulating influence of a regular influx of new trainees. Such hospitals would provide a limited emergency service and general medical and surgical service for both elective and emergency patients, with Intensive Care Units and High Dependency Units, This would require sufficient Consultants staff to provide a sustainable rota of specialists with, for example, a minimum of three Consultants in Radiology and Pathology services sufficient to support the acute specialities". page 21 11.3, 11.4

The recent visit of the Royal College of Physicians and Surgeons Review Body at the request of the Royal Cornwall Hospitals Trust, would appear to have totally and illogically discounted the above statement.

· "The key to the availability of acute and emergency medical services perceived by any community is the availability of an A&E Dept" page 27 15.1

totally agrees.

· "A&E units are facing an inexorable rise in attendances" page 27 15.2

	*That statement is undeniable.*
	So, in order to overcome this inexorable increase, it is proposed that the ONLY A&E department in Cornwall be situated at Treliske! This is a hospital which cannot cope today, never mind adding to its workload.
	*Why is it that the NEED for an A&E department at West Cornwall Hospital seems to be clear to everyone except those connected with the NHS?*
	*When are they going to start fulfilling the key promise of the NHS Plan … basing decisions on PATIENT’S NEEDS?*

THE ENTIRE JOINT CONSULTANTS’ COMMITTEE PROPOSITION RELIES ON HAVING HEAVILY POPULATED AREAS. WHERE THESE DO NOT EXIST THEY INTEND TO CREATE THEM BY CLOSING OR REDUCING EXISTING SERVICES AT LOCAL HOSPITALS.

REDUCING SERVICES WILL FORCE PATIENTS TO TRAVEL TO THE MAIN HOSPITAL, IRRESPECTIVE OF TIME, DISTANCE, INCONVENIENCE, COST, STRESS OR POLLUTION.

The Report from the Royal Colleges Review Body stated …

	If most of the acute Medical and Surgical work ceased in West Cornwall Hospital then it is clear that the Royal Cornwall Hospital (Treliske) would be unable to cope.
	Indeed there is already a continuing crisis situation in the Trust, with frequent transfer of patients from one hospital to another.

· Patients and relatives are already being asked to travel too much. Review Body Paper, page 23 9.0

Section 9

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A POSTCODE LOTTERY?

	*Are the services currently provided by West Cornwall Hospital, typical of a hospital serving a population of approximately 150,000?*
	*The answer is a resounding "NO!"*

In referring to A POSTCODE LOTTERY we are aware that the Services available in areas of London or Birmingham are not as readily available in Cornwall, but what about areas which have similarities to West Cornwall?

We take but one case as a comparison and it just so happens that it is relatively local. North Devon's District Hospital at Barnstaple serves a population of 153,000.

Hospital	Barnstaple	W C H
Bed capacity	423	81
Elder Care beds	70	6
General Surgery beds	79	27
General Medicine beds	58	38
Admissions Unit beds	0	6
Mental Illness beds	47	0
Trauma & Orthopaedic beds	45	0
Obstetric beds	30	0
Gynaecology beds	24	Day cases only
Elderly Mentally Ill beds	24	0
Opthalmology beds	3	0
ENT beds	5	0
SCNU	8	0
Intensive Therapy beds	6	0
High Dependency Unit	0	4
GP Acute beds	3	0
Oral Surgery beds	3	0
Haematology beds	5	0
Dermatology beds	3	0
Rheumatology beds	1	0
FULL Accident & Emergency Dept	Yes	No

· “Today, successful services thrive on their ability to respond to the individual needs of their customers. We live in a consumer age, services have to be tailor-made not massed produced, geared to the users NOT the convenience of the producers.” NHS Plan page 26 2.12

Which of the above two hospitals best meet these statements? If the planners get their way and more services are transferred to Treliske, how will West Cornwall Hospital then relate to these statements? The answer is not at all. Therefore we in West Cornwall are, and will even more be, excluded from the full benefits we were promised in the NHS Plan.

Section 10

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SUMMARY

	is not affiliated to any political party. Members are elected to the committee of which represents the general public on health matters in West Cornwall.
	When we read the government’s White Paper we were impressed. It put the patient first; it talked of a bottom up approach; it stated that the NHS would be designed around the patient, not the other way round.

Indeed it would be NEEDS LED and EVIDENCE BASED – and we believed it.

The perception of the population in West Cornwall is that their voice is not being heard the views of the medical profession and in particular the two Royal Colleges are taking precedence, and by taking this route the job of the NHS planners is made easier.

This perception needs to be changed – by a needs-led evidence- based option, and by a change in the attitude of those who make the final decision. Unfortunately, since the publication of the White Paper and the NHS Plan, no real change has been forthcoming in West Cornwall. We accept that change of the magnitude envisaged will take time, but we have not even seen evidence of a change in the process and attitude of our local NHS planners, the Cornwall and Isles of Scilly Health Authority. Decisions are required of them on the key issues that the White Paper and NHS Plan address, but there is a danger that the lumbering bureaucratic processes that have clogged the modernisation of the NHS over past decades will persist.

We have been assured that the Public will be presented with a thoroughly examined, balanced set of options.

have been given many such assurances in the past. Sadly, events have proved that we are right to remain sceptical.

The instant "welcoming" of the recent report from the Royal College of Physicians and Surgeons Review Team, is a classic example of this one sided process.

The decision-makers within the Health Authority must take on board the concept of balance by both listening to and taking into account the views of all parties – the professionals AND the general public.

The public must be kept fully involved in all the options that are being considered so that they can be part of the ensuing dialogue and debate.

It is their health under review.

The future of the NHS in Britain as laid out in the NHS Plan is a step-change in thinking, by putting the patient first. It needs an even larger step-change by the NHS managers/planners to see it through to implementation. The selected option has to be the one that is in the very best interests of the patient.

The final decision-makers for West Cornwall Hospital, after statutory consultation, are the NHS Executive Forum (previously known as the Accountable Officers Group), and it is to them, that we commend this -