This is a longer version of the interview with Epsom Hospital Chief Executive Daniel Elkeles which features in the Spring issue of the Newsletter. Mr Elkeles was answering questions on the future of hospital services put to him by FRA Vice-Chairman Ian Anderson.
Q: The future of Epsom Hospital has been an issue for many years. Why is it different this time?
DE: This is a once in a lifetime opportunity to resolve ‘what to do with Epsom and St Helier hospitals’. We have never had £500m set aside for us before. That amount of money builds you a brand new specialist emergency care hospital, and the refurbishment of the Epsom and St Helier sites. The money is now sitting there waiting to be spent. In the past, the proposals to rebuild have always been speculative because no-one has had the money.
This the first time, in living memory, the case has been made compellingly, that you need to sort out the future of Epsom and St Helier, that the right answer for the 500,000 people who use Epsom and St Helier is to have a brand new state of the art hospital for when they are acutely unwell. We have made the argument, and the Government have said they want to fully fund the building of six hospitals and we are one of the six. We need to deliver this.
Q: By taking A&E and maternity services away from Epsom (to Sutton) this looks like a downgrading of our local hospital.
DE: In all of the options we are proposing 85% of patients will continue to get care at Epsom and St Helier. That means an urgent treatment centre, which is what two-thirds of people go to A&E for, all of outpatients, all of diagnostics, planned care – so the orthopaedic centre stays at Epsom. And there will be a lot of in-patient beds - mainly for elderly people who need to be in a hospital bed to convalesce. So the vast majority of what people will use a hospital for carries on, but in refurbished buildings.
We are consulting on consolidating six acute services into one site and of course one of the options for the site could be Epsom. These are the services for when you are very, very unwell. The reason we need to consolidate them is predominantly because we don’t have enough doctors and nurses to deliver the quality standards we would like to deliver, so that no matter what time of day, or day of the week, someone gets very unwell, they can be treated to the same high standard of care.
If the answer was as simple as 'we could recruit more of these people' and deliver the quality standards at Epsom and at St. Helier in the current service configuration we would have done so. We have tried everything to recruit enough people to meet the quality standards and there are just not enough people available to recruit, either in this country or abroad.
Q: So why does building on a new site help this problem? Won’t you have the same recruitment issues there as well?
DE: The specialist emergency care hospital will only have 6 services (A&E, acute medicine, emergency surgery, critical care, births and inpatient paediatrics). It will be the 6 services for the areas that we can’t get enough people to run the services to the quality standard we require, twice. The two most difficult to recruit to services are A&E and Acute Medicine. The other 4 services need to be co-located because there is a set of dependencies.
For example, if your get blue-lighted to A&E and you are exceptionally unwell, you are likely to be admitted to hospital, either to be under a physician for emergency medicine, or because you have got an emergency surgical condition and need access to surgeons, or you are really unwell and need to go to critical care. These four services which work together and need to be located in one place. One of the big advantages for Fetcham residents of this model, is that currently, many Fetcham residents get admitted to Epsom A&E, but because Epsom doesn’t have emergency surgery or critical care, they then get transferred to St Helier which is quite a long way from where they live.
Guildford Hospital would actually have been closer (the other hospital that Fetcham residents can access) and Guildford does have A&E, emergency surgery and critical care on one site. So in this model Fetcham residents will either be able to go to Guildford, or if the preferred location is Sutton, to access those services in one place, and that is considerably closer than St Helier.
Q: In that sense it is a better option than what we have now?
DE: It is.
Q: There must be circumstances where people will have to travel further from this area?
DE: Remember that nearly service that people use in a hospital will remain at Epsom, so there is no change to travel times at all. It will be for the services where you are very unwell that there will be a further distance to travel. Nearly everybody who is very unwell phones 999 and goes by ambulance.
"In each of the 3 proposed options, the timing remains the same, i.e 99% of people will get to A&E within 30 minutes."
We have done detailed modelling of ambulance travel times and in the current service configuration, 99% of people can be picked up from their home and get to A&E within 30 minutes. In each of the 3 proposed options, the timing remains the same, i.e. 99% of people will get to A&E within 30 minutes.
Q: Is 30 mins a national criteria for getting to A&E?
DE: There is no national criteria, but people will have heard of the ‘golden hour’ when emergency treatment should commence. So a travel time of 30 mins or less is clearly very much within the golden hour. But also, an ambulance isn't just a taxi, it's like a mobile intensive care unit, so once the paramedic, a trained clinician, has got to you, their ability to stabilise you and give you initial treatment is very high.
In all the national evidence, a small increase in travel time actually leads to better outcomes. That’s because the small increase in travel time is far compensated for by getting access to a highly-trained specialist when you arrive at hospital who can make a definitive diagnosis and start the right treatment. That’s what saves lives, and that is why we are so keen to meet the quality standards for emergency services.
Q: The urgent treatment centre doesn’t sound nearly so good as a gold standard A&E?
DE: They are different, but what most people don’t realise is that when they come to Epsom or St Helier A&E, they are actually treated in an ‘urgent treatment centre’. A lot of our staff are emergency nurse practitioners and GPs, and it is they who treat you. If you come in with a sprained ankle, or a temperature, or something stuck in your eye, you are being treated in the urgent treatment centre and all of that stays, and will be open 24/7 (unlike a minor injury unit which is not open 24/7).
Two-thirds of people who come to A&E are already treated in the urgent treatment centre. There is a sign currently outside Epsom A&E which says 'A&E; urgent treatment centre; GP out of hours; GP walk in centre’. These are 4 services all located in the same space with different professionals running them, but you don’t notice that as a patient.
Q: If I or a member of my family is injured, how will I decide whether to go to the urgent treatment centre or to A&E?
DE: If you are unsure whether someone needs to go to hospital, you can phone 111, or phone 999. Use your judgement, but whatever you do and wherever you end up in the system, the hospitals will ensure that you get to the right place for your specific injury or condition. Even if you are very sick and you come to the urgent treatment centre, and it’s not the right place, the staff are qualified and competent to be able to stabilise a patient so they don’t get worse, while organising the care in the right place.
Q: Looking at the consultation documents, I might think it is geared to people living in Sutton or Epsom, and it ignores Bookham and Fetcham.
DE: Fetcham and Bookham are on the edge of the current Epsom/St Helier catchment area and are in fact pretty equidistant between Guildford and Epsom.
In the Sutton Hospital option, you get to the scenario, where Fetcham is closer to Sutton, but Bookham is closer to Guildford. We have modelled that there is a flow from Fetcham and Bookham to Guildford. We have also factored in from these residents that they like Epsom Hospital and want to carry on using the services that Epsom want to keep.
We have therefore planned some people choosing to use Guildford, and some using Sutton, and whatever people decide to do we will make sure we have the capacity to make it work.
Q: Will there be a bus service to Sutton?
DE: Most people who travel to the specialist emergency care hospital are going to go by ambulance. The length of stay is going to be short, because we are going to do rehabilitation at both Epsom and St Helier. The travel access we need to worry about is for people coming to visit people. There isn’t a bus service from Leatherhead to Sutton, but the point of the consultation is to find out what people want. The NHS is paying for the H1 bus already. The whole point of the consultation is to listen to what people say about this.
Q: Epsom is a cheaper option in cash terms than Sutton so why can’t we keep £50m and build at Epsom?
DE: The specialist emergency care hospital on the Epsom site is the cheapest, because it’s the smallest. That is because the most dense part of the catchment who use Epsom or St Helier, live north of Epsom hospital. If you located the specialist emergency care hospital at Epsom, it would not be the closest hospital for many people in the Boroughs of Sutton or Merton. St George’s and Croydon Hospital would be closer.
"I can tell your readers, as can all the clinicians at Epsom and St Helier, that no change is not an option."
The modelling says that you would have to build a 100-bed extension to Croydon Hospital and a 100-bed extension to St George’s Hospital if the specialist emergency care hospital is located at Epsom. So the total capital required for the NHS is actually similar for all 3 options. Whilst the Epsom option is the best value for Epsom and St Helier, because the costs of servicing the capital is smaller (because the building is smaller) for the whole NHS it is the worst financial return, because Croydon and St George’s don’t make any gain to their finances. We would save money from having it in Epsom, but in fact that option is going to cost more over in Croydon.
The metric that the Treasury use is what is the net present value (ie overall rate of return) not for Epsom and St Helier, but for the NHS over 50 years. When you apply that calculation, Epsom has the least good net present value, St Helier has a better net present value, but Sutton has the best.
Q: You mentioned investment in Epsom Hospital, eg refurbishment, can you mention any specifics?
DE: We know that our local communities are very fond of Epsom and St Helier hospitals and it is also clear that these hospitals have been starved of investment for decades.
We have now commenced the energy centre at Epsom that will cost £8m, and in a year’s time Epsom Hospital will also have a new combined heat and power plant. This year scaffolding will be erected around the 1960’s built Wells Wing of Epsom. The roof leaks, the windows need replacing, the exterior needs attention and that work will be an investment of £7.5m.
Car parking is a nightmare on the Epsom site and we are submitting a planning application for a 350-space multi-storey car park. All of those investments are not funded by the £500m we have recently been awarded. They are happening anyway to improve Epsom Hospital. £80m of the £500m allocated for the building of the specialist care hospital, will be used to refurbish the inside of the buildings that we want to carry on using.
Q: Is this a genuine process?
DE: If it wasn’t a genuine process, we would not be investing as much time and effort on engaging with the 500,000 people who use Epsom and St Helier as we are. All residents should have received a leaflet in the post saying that we are undertaking a consultation. We are having 9 public meetings, deliberative events, residents surveys, we are coming along to any group who wants to hear what we are proposing - this is a huge endeavour to ensure we are engaging with people for whom we serve.
Q: We currently have a Draft Local Plan looking at a population increase of 14% by 2033. Has that process been built in to your calculations?
DE: Yes, we have modelled, that if the new emergency care hospital is due to open in 2025- 2026, there will be 30,000 extra people in our catchment. We have taken account of that in all our modelling. 30,000 extra people would mean 60,000 extra attendances at our hospitals. So we have modelled quite a big increase in activity.
Q: If people think it's a good idea do you want to hear that it is a good idea?
DE: Yes, we think that the silent majority of people would think that having £500m to spend on building a state of the art hospital for when you are very unwell and keeping 85% of services local in refurbished buildings, is a good thing. We need all those people who think that to tell us. Everyone can see there is a small group of people who are very vocally opposing what we are doing and that the right answer is no change. I can tell your readers, as can all the clinicians at Epsom and St Helier, that no change is not an option.
No change will lead to Epsom and St Helier losing services over time because you can’t sustain the unsustainable for ever. What we are proposing is an answer that provides fantastic buildings but also completely sustainable high quality care that the NHS can afford for generations to come. This will be the last time that we have to have a consultation with the public about the future of Epsom and St Helier because it could be about to have the most amazing future. So if you think this is the right thing to do, PLEASE fill in the consultation form. Also, if you think we have missed something, please fill in the form. We are in listening mode and we need to hear if we haven’t got it right and there are other things we need to think about.
Q: The consultation is not a ‘vote’?
DE: That’s correct, If it was, the loudest voices would win. We want to hear people’s views about whether the arguments we are making are right.
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