CROYDON COMMENTARY: Amid the mounting controversy about the effectiveness of the NHS’s 111 phone line service and junior doctors working all hours and over weekends, the local CCG – Clinical Commissioning Group – has been putting forward a case for a re-organisation which would diminish services in the south of the borough, says IAN HUNTER

I joined the debate late in the day on how the Croydon Clinical Commissioning Group (CCG) was to take forward requirements for providers for urgent care after 2017, when the present contracts expired, by attending a meeting organised by Chris Philp, Croydon South’s MP. This is my take on the matter.

The meeting, at Christ Church, Purley, was the final “engagement” by the CCG. It was extremely well-attended, after similar gatherings had been going on for the better part of a year. The discussion paper was entitled, somewhat pretentiously, “Right Care, Right Place, First Time Involving Croydon in improving urgent care”.

The discussion was lively, with the CCG representatives looking somewhat uncomfortable for some of the time. I came away from the meeting with some serious concerns about the way the CCG were seemingly ignoring the wishes of the very people for whom the facilities at Purley Hospital are intended and so, responding to the invitation to “get involved”, I did. I set down my thoughts and some questions (11 in total), and emailed them to the group.

This occasion was not the first attempt by NHS Croydon to look to the future of health practice in the borough.

A 2007 assessment of the future Primary Care strategy in Croydon was presented as a “Consultation” document. It was not well received and many of its suggestions were comprehensively rejected by local people who, between March and May that year, had the time to consider the proposals carefully. As a result, in October 2007, the Croydon PCT Board agreed not to take the proposals forward in the form presented.

The latest paper, presented on January 7 this year, was the result of internal CCG deliberation based on feedback and, according to CCG, this time it was an “engagement” not a “consultation”. A poor attempt was made at the meeting to explain the difference. In response to my first two questions, I was told the “engagement” activities were much more open-ended and flexible than “consultations”.

Public consultations, it was said, were time-limited and have to be distributed and carried out in particular ways. The CCG highlighted the ability to adapt its engagement to local needs and to continue to respond to invitations to present to interested residents beyond the formal close-of-survey date (which was January 20). The refinement process resulted in Option 1 of the three presented to the meeting – of three GP “hubs” established in New Addington, at Purley Hospital and in Edridge Road – being accepted for further progress, but with the opportunity to refine the model and specification up to February 29. After that date, there is no purpose in seeking to change the proposal.

To be the site of a new GP hub. Just don’t expect to walk-in if you’re unwell and needing urgent treatment

A number of additional “Frequently Asked Questions”, developed in the light of comments at the January meeting were incorporated in an Urgent Care PPI Engagement Report, but their effect has not changed the actual basis of the intended tender brief.

My next concern was the way the CCG sought to ensure that for any Hub, appointments will made by the 111 service, with a throwaway to “the acceptance of walk-ins”.

A recent nose-bleed, which gave experience of that 111 service, exposed a flaw related to the provision (actually, non-provision) of Ear Nose and Throat (ENT) department facilities at Mayday Hospital on weekends. The 111 service recommended that I go to the Mayday A&E for assessment. I was recorded in at 11am, but by 1pm I was transferred to St George’s Hospital in Tooting by ambulance, where full ENT services were open. After a 40-minute ride through heavy traffic, I was kept in for two days for treatment.

On page 15 of the document “Croydon Urgent Care Re-procurement Appraisal Public Engagement – final”, it reveals that the national strategy for the 111 service is that it “will also be able to book people into the right service, first time within the GP hubs including primary care, community prescribers and the Urgent Care Centre”. However, CCG backed away from saying anything about the co-ordination needed to keep up-to-date the 111 service information regarding availability of weekend facilities around the borough. “The NHS 111 procurement is a separate procurement with its own processes and timescales”.

I pressed the issue of the present walk-in value at Purley Hospital under the proposed hub. No attempt has been made to assess its current worth, based on the Edridge Road walk-in centre experience. CCG says that only close monitoring of future urgent care use will provide such an indication. Yet the hub at Purley Hospital will, according to the CCG, provide the same services as Edridge Road, plus a minor injury unit and more. CCG means to expand upon the 23 specialist services plus their staff, skills and equipment which are already in place and operating out of the hospital, following its recent £11 million upgrade. All services now at the Purley site appear to be under an appointment system controlled by the front desk or a ticket system.

CCG’s seemingly dismissive view of the walk-in system implies the introduction of an arrangement which favours 111-booked appointments. The risk is that the walk-in service will disappear.

There are growing reservations about the capabilities of the re-branded NHS 111 service

At the new hubs, the length of wait for a walk-in patient seems likely to depend on the number of 111-booked appointments, unless the condition of that walk-in person deteriorates to the point where they would be allowed to jump the queue. Has anyone modelled that scenario?

The Urgent Care Re-procurement document compares and summarises nine scenarios against a common set of seven parameters. I noticed several things regarding the content of the scenarios.

In every instance under “affordability” there is no reference to the value of the “Financial Envelope” – the budget of available funds for the task. It even fails to show, at Scenario 7, the financial element of the current service, making it impossible to judge real quality and worth.

Several scenarios refer to the on-going refurbishment work to the Emergency Department at Mayday which also involves upgrading out-of-hours services. Have these costs been included in the “Financial Envelope” baseline, and doesn’t that make it all the more important that the baseline should have been revealed in each of the scenarios?

With Mayday expected to pick up the bulk of the Edridge Road walk-in activities, presumably the way will be clear to close that site, thus depriving the thousands of new residents expected in the centre of the town of a flexible, local medical hub?

The Edridge Road walk-in centre, close to the Flyover. Will the NHS look to close this centre when Mayday’s new A&E opens?

Throughout the document and the January meeting ran the themes of “expansion and improvement”, “extension not reduction of services”, “improved accessibility of services” and ” provision of the same services at the walk-in centre and more”.

Although in their comments on each scenario the CCG provided detailed evidence to show the complications of creating an urgent care patient at Purley, or providing an out-of-hours service, the paper seen at the meeting made no reference to any previous discussions on the matter with NHS England. That body’s desire to maintain a commonality of procedures across the country seems to have made the CCG baulk at seeking even approval in principle for the creation of other Urgent Care Centres in the borough that are not tied to Mayday’s location. I find it quite absurd to read that the option for additional Urgent Care Centres (at Mayday and at Purley) would not meet the criteria as the viable options being proposed.

What criteria are they, that do not now exist at the Purley site, and how much would satisfying them cost?

I would have come away from the meeting happier had we been told if the “Financial Envelope”, which Scenario 6b exceeded by a mere £2.16 million, had taken account of the existing facilities provided on the re-furbished Purley Hospital site, and had been directed towards the costed evidence to support this.

The procurement of the emergency care facilities at Mayday was deemed to be outside the scope of this paper. But the improvement of Croydon’s Urgent Care facilities was not, even though the paper contradicts itself by stating that the review only relates to Minor Injury Unit services.

The document states that the future Croydon Urgent Care model must incorporate the national and regional direction of travel. Not knowing exactly what that meant I asked the CCG if they were saying that the Borough cannot tailor those standards to local circumstances and did that in turn mean that only one Urgent Care Center is all that can be authorised? The response appears to suggest that an Urgent Care Centre has to be co-located with an Emergency Department that meets the set of national standards.

Yet Mayday itself fails to meet all of the London Quality Standards, the minimum standards for emergency services supported by all 32 London CCGs, including Croydon. That standard requires hospital trusts to provide consultant-delivered services seven days a week, including evenings and weekends. Apparently, this does not apply to Mayday’s ENT department.

The CCG’s document even states that “the sufficiency of GP and primary care service availability and call-handling capacity commensurate to meet demand 24/7 must include weekends and OOH [out-of-hours] service before 8am and after 8pm every day”. The proposed GP Hubs come nowhere in meeting that requirement.

The recommended option confines the new service to a 12-hour day (8am to 8pm). It offers a GP Out Of Hours service, though not at Purley – a bone of contention- but doesn’t say what the opening hours are. When it refers to “the same site”, it means that currently occupied by Mayday, its Urgent Care Centre and the A&E facility. Whereas an out-of-hours clinic in the south of the borough associated with a 24/7 health complex based at Purley Hospital offers a more balanced service to that area. So, again, no value for patients in south.

Purley Hospital: would an urgent care centre here provide a better service for residents from the south of the borough?

The CCG criticism of Option 6b – which suggested three GP hubs and two Urgent Care Centres – of increasing the challenges treating children and young adults is not supported by pediatric evidence and is not a valid reason for rejecting this scenario.

Croydon Council is attempting to provide more than 8,000 homes in the centre of the town, in order to please City Hall. It is unquestionable that the occupants of those new homes will have their share of children, young and old adults. If the council cannot resist overloading accommodation in the town centre, then the least it should do is retain the existing walk-in centre in Edridge Road and expand its functions by encouraging the CCG to put a GP hub there.

The CCG says that national evidence shows that 20 per cent of GP consultations are for minor ailments that could have been seen elsewhere, such as in pharmacies. This figure is an alarming indictment of the hypochondriac culture of this country. My concern is how relevant that statistic is to Croydon. How was the data for the area covered by the CCG exercise collected and how different is it from the national trend? I think we should have been told, so we could get our own health regime in order.

I understand that if enough major changes are required to be made to the paper before submission of tender documents (due in April 2016 – I think), those who responded to the invitation to “engage” should have the opportunity to attend some form of Public Inquiry which considers the issues further.

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