14 March 2024
This report can be downloaded as a pdf file here.
IN A NUTSHELL
The Mid and South Essex Integrated Care Board is seeking to close St Peter’s Hospital, a community hospital in Maldon. It has put forward two alternative proposals for public consultation. Neither allows for using the existing hospital buildings, which it claims are unfit for use. These currently accommodate inpatient beds for patients receiving intermediate (step-down) care after treatment in an acute hospital: until recently there were also beds for patients in a stroke recovery unit. The Hospital also currently accommodates a unit providing freestanding midwife-led birthing services, and a wide range of outpatient clinics.
In January 2024 the Mid and South Essex Integrated Care Board published Public consultation (commonly referred to as the Consultation Document),[1] which invited the public to submit ‘views and ideas on our proposals for future arrangements for inpatient services at our community hospitals … and other patient services provided at St Peter’s Hospital, Maldon’. It put forward two proposals, both of which involve closing the hospital completely and moving all the inpatient beds, as well as all the birthing services and all the outpatient clinics, elsewhere. The site would be sold.
The sequence of events so far is eerily similar to those in the case of the Edward Hain community hospital in St Ives, Cornwall, which have been documented elsewhere.[2] In essence, there has been a systematic process of blight: buildings have been allowed to run down and some services have already been moved elsewhere, yet the public are being told that these service changes are temporary and that no decisions have yet been taken.
This note documents this process in relation to St Peter’s Hospital. It argues that by virtue of what has already taken place, the current so-called ‘consultation’ on the two proposals is duplicitous. The central issue here is what could be done to renovate and modernize St Peter’s Hospital: that third alternative should be fully developed and presented so that an honest public consultation can take place.
The Consultation Document is presented as ’a summary of our full pre-consultation business case, which is a large technical document … available on the consultation website’. That Business Case was prepared by a Community Capacity Task Force: it too was published in January 2024.[3]
At the present time public consultation is already under way: it was originally due to close on 21st March 2024. (The closure date has now been put back by two weeks.) This note presents some observations by an outsider on the decision-making process and the reasoning it reveals.
1. The Consultation Document amounts to an attempt to mislead the public into thinking that all possibilities remain open.
The public have been told: ‘The proposals that we are describing are just that: proposals. We are asking local people to share their thoughts before we decide what to do. We will consider your responses carefully and take them into account when we’re making decisions about these proposals.’ But prior to public consultation numerous possibilities, including all those that involved keeping St Peter’s Hospital going, have already been ruled out. Decisions have already been taken, by default.
2. The Consultation Document includes a ‘decision tree’ {s.5.2.6) which reveals that any and all options involving keeping St Peter’s Hospital open were ruled out by a Task Force very early in their work. This has not previously been made public.
The decision tree (s.5.2.6) shows that a six-stage sequence of questions and answers was followed. The very first stage asked: ‘Does the option use St Peter’s?’ Since the answer was affirmative, the response had to be ‘Eliminate’. That decision, which ruled out further consideration of any option that would involve keeping St Peter’s Hospital open, must have been taken in the summer or autumn of 2023/24. It was kept from the people of Maldon until two months ago.
The Task Force has been at work since the Summer of 2023. The Business Case that it produced has only recently been published. The public have not been told who the members of the Task Force were. But the Business Case tells us that early in its work there took place a ‘review by clinicians’ from which ‘a short list of options was prepared’: from this ‘Option 4 was selected as clinically the most appropriate arrangement to enable the system of health and care to respond to expected demand over the winter of 2023/24 … None of the options considered continuing the use of St Peter’s Hospital … as its condition was considered to be unsuitable for continued use for inpatients’. (s.5.2.5)
Subsequently a further review of options was completed, ‘using weighted criteria reviewed by clinicians’. We also find a reference to the Task Force having ‘a clinical sub-group’, while ‘shortlisting has been undertaken using clinical opinion …’. (ss.3.3.5, 5.2.6)
Two things stand out here:
(1) Clinicians were in control over the process of selecting and narrowing down the options considered: notably – in the very earliest stages – they ruled out the future use of St Peter’s Hospital.
(2) The clinicians involved appear to have had no thought of consulting the public during their decision-making process. One wonder how far even lay members of the Task Force were involved.
3. St Peter’s Hospital appears to have been deliberately allowed to run down. If that had not been the case, the faulty roofs would have been dealt with, at a manageable cost, preventing disruption and damage caused by water ingress.
An ‘Estate Briefing’ has recently been made available.[4] It shows the total funds required to address backlog maintenance for St Peter’s Hospital as being £20 million. To repair the roofs of the main block and outpatient building, thereby preventing further water damage and avoiding the use of buckets to catch rainwater, would cost just £497,000, less than one-fortieth of that total. Undertaking those repairs would clearly have given good value for money.
That the building has been neglected so badly suggests that the freeholder, the MSE NHS Foundation Trust, as custodian of the building, has been in dereliction of its civic duty to the people of Maldon.
4. No-one seems to have asked: ‘What do we see if we look at St Peter’s Hospital building and site as an opportunity?’
It appears that the minds of the management of the MSE NHS Foundation Trust have been closed to possibilities other than complete shut-down of the Hospital. It may be that lay members of the Trust Board were unwilling to challenge the clinicians. Notably, the Task Force seems to have offered no opportunity for Maldon Council or the voluntary bodies in the town, let alone the public, to join with the local medical community to consideri the potential of the building and site as a refurbished and reinvigorated community hospital.
For example, could not a rejuvenated St Peter’s Hospital incorporate an Intermediate Care Unit led by therapists and focusing primarily on rehabilitation? It could provide inpatient beds and associated clinics as well as therapies, the aim being to minimize patients’ length of stay after they had been treated in an acute hospital. (In some cases it would allow people to avoid being admitted to an acute hospital in the first place.) The rejuvenated Hospital could also accommodate all the outpatient clinics and diagnostic facilities for which new accommodation is currently being sought in and around Maldon in anticipation of St Peter’s closure.
The absence of open-mindedness as to the Hospital’s future is perhaps suggestive of weak management on the part of the Integrated Care Board.
5. The members of the Task Force have not properly understood the role of intermediate care in community hospitals.
Community hospitals are not just elements in a ‘spectrum’, as the Business Case describes them (s3.2.2). Rather, they provide essential stages for patients in a process, their ‘care journey’, the transition from the acute hospital where they have been treated to their home or other place of residence.
For example, an elderly person living with frailty who has suffered a fractured neck of femur will receive surgery at an acute hospital and then be transferred – in a ‘step down’ – to a community hospital closer to home for reablement/rehabilitation en route to their return home. Closeness to home and the sense of being on the journey there play a crucial part in keeping up patients’ morale and keeping their need for institutional care at bay.
In the Maldon local authority area, the population increased from around 61,600 in 2011 to 66,200 in 2021.[5] Over that period there was an increase of one-third in the number of people aged 65 years and over. While St Peter’s Hospital has been running down, the need for step-down care in Maldon has increased. This dynamic can be expected to continue. Because of Maldon’s coastal location, access to community hospitals elsewhere is particularly limited.
Where does Maldon go from here?
From the outside, and based on first-hand knowledge of what happened in the case of the Edward Hain community hospital in St Ives, it is apparent that there is a wide gulf between the people running the current public involvement events, who insist that the proposals up for discussion are no more than proposals, and the clinicians, operating behind the scenes in the Task Force, who very early in the decision-making process ruled out any options that would make use of St Peter’s Hospital. It does not seem to have occurred to either group that there could be benefits from taking members of the public with you through your thought processes. There has to be more to public participation than inviting lay people to ‘have your say’ after crucial decisions have already been taken.
In my experience, the man and woman in the street tend to resent being asked to rubber stamp decisions that have already been taken, especially any that exclude options that they favour. Consigning St Peter’s Hospital to the knacker’s yard could prove to have been one of those decisions.
So my message to both groups, MSE managers and clinicians, at this point is this: If you get a hostile reception, be aware of the reasons for it and be prepared to go back to the drawing board.
I repeat: You need to take the public with you in your thinking. Most people understand dilemmas, and will appreciate the difficulties you face. But if you ask them to rubber stamp decisions that you have already taken, expect to be challenged.
Peter Levin.