Written evidence submitted by Dr Sally Ruane
- I am a Reader in Social Policy at De Montfort University, Leicester, and a member of the public hoping with others to benefit from the acute and maternity services reconfiguration of the hospitals comprising University Hospitals of Leicester. This is a cohort 3 scheme.
Local scheme and context
- Plans to reconfigure the three hospitals, the Leicester Royal Infirmary, the Leicester General Hospital and the Glenfield Hospital, date back over 20 years. The hospitals primarily serve the population of Leicester, Leicestershire and Rutland. The scheme chosen by the Trust and CCGs was costed at £450m in 2019 and a pre-consultation business case was approved in a public meeting of the CCGs’ governing body in September 2020. The proposals went to formal public consultation under the name of Building Better Hospitals For the Future in September-December 2020.
- The proposals were to consolidate acute hospital services onto two sites, with the closure of the Leicester General Hospital as an acute hospital. To help separate elective from emergency care, a Treatment Centre would be built on the site of the Glenfield Hospital and a new maternity hospital would be built on the site of the Leicester Royal Infirmary. A children’s hospital would be created largely through refurbishment and the number of intensive care beds would be increased.
- The proposals were broadly supported but there was significant public disquiet about travel and transport in part arising from the planned closure of the General Hospital perceived to disadvantage those on the Eastern side of the geographical patch. Concentration of services at the Leicester Royal Infirmary by contrast meant additional building on an already landlocked site with all of the access and parking challenges of a city centre location. The Leicester health overview and scrutiny committee questioned the value for money to the public of selling off a large swathe of the (relatively accessible) General Hospital estate. There was also public disquiet about plans to remove expectant mothers’ access to a standalone midwife-led birth centre, one of the four options to be offered to mothers in the NICE quality statement. In response to this the CCGs strengthened their commitment to this birth option in the decision-making business case proposals approved by the CCGs in June 2021.
Lack of transparency
- Since then, the scheme has suffered severe delays. Between 2021 and 2023, some design work was undertaken but overall there has been little visible progress on the scheme. The public has been given little information about the scheme and its progress since 2021, quite possibly because local NHS leads may have felt there was little to tell the public while at a national level no decision had been made about funding. Minimal information has been brought to the public board meetings of either the Hospital Trust or the Integrated Care Board, the successor body to the CCGs’ governing body which has overall responsibility for the scheme. The implications for the scheme of the new ‘elective care hub’, funded separately through the Targeted Investment Fund, were not discussed at public boards.
- This dearth of information meant that since the Secretary of State made his announcement in May 2023 about the funding of the schemes in the New Hospital Programme (NHP), the public has had little understanding of what is being funded. Public questions posed at board meetings have drawn relatively vague responses: that the “preferred option” is being “fully funded”, without clarity for the public regarding either the scale of the funding or the nature of the “preferred” scheme.
- Not only is the level of funding for the scheme being withheld from the public, but the estimate on which that level of funding has been determined and the date the estimate was provided are also unknown to the public. As the passage of time itself erodes the real terms value of any funding pledge because of general and construction sector specific inflation, funding levels agreed today, possibly on the basis of estimates provided yesterday, will be inadequate for building work which does not take place till tomorrow. This creates continuing uncertainty for the public.
- Local NHS leads referred to their “preferred option” back in 2021 and again more recently in 2023 to their “preferred option” with no clarity for the public regarding whether this term refers to the same scheme content or whether there has been change in the “preferred” scheme over time. When Trusts in cohort 3 were asked by the NHP team in July 2021 to submit three different options, including a preferred option, a cheaper option and a phased option, these were not placed in the public domain and requests in health overview and scrutiny to specify the content of these options were refused. Thus, it is some time since the public had a clear understanding of the evolving thinking of local NHS leads regarding the scheme.
- There have been some indications that the content of the scheme might be altered in material ways when compared with the approved scheme set out in the 2021 decision-making business case. For example, opinions expressed by a local NHS lead suggested that the rapidly rising costs of the scheme made it questionable as to whether the 2021 scheme, agreed in the CCGs’ decision-making business case, would be fully funded. The new ‘elective care hub’, funded separately through the Targeted Investment Fund, is expected to perform 100,000 procedures annually when it is fully up and running by the end of 2024. Its siting at the General Hospital has implications for the Treatment Centre initially planned for the Glenfield site. Significant changes in the hospital trust leadership since 2021 might also have been expected to lead to differences in vision.
- In sum, the insistence by the Secretary of State that the amount pledged for each scheme should remain secret from the public on the grounds of commercial confidentiality and sparse communication by local NHS leads leave the public in the dark regarding how much the public as taxpayers will be paying for the new hospital scheme and precisely what this scheme will consist of. We can add to this a lack of clarity regarding timeline given the NHP’s commitment to a centrally determined model of hospital construction and its ongoing difficulty in defining and agreeing this. This gives the impression that whether the public perceive the scheme to represent value for money is considered unimportant.
The impact of combining multiple schemes into one programme
- The decision to create a programme of 40 more or less simultaneous hospital schemes seems itself a strategic error given the complexity of delivering even a single new hospital when the requirements of contemporary and anticipated health care need, modern technology, pandemic-proofing, environmental considerations, logistical complications, scheme and site specific matters and other design considerations are taken into account. After a decade in which large scale capital investment in the NHS was deprioritised, it could be expected that the DHSC/NHS England might not possess the capability to undertake such a large scale programme. Wrapping individual schemes into a single programme appears to have had a paralysing effect, at least on cohort 3 schemes. Valued staff who undertook detailed work on our local scheme in the past have been lost.
- Ironically the delays created by trying to define Hospital 2.0 themselves add to the inflationary effects upon the costs of individual schemes. The decision to wrap individual schemes into one overarching programme, by multiplying complexity and costs at a time of post-pandemic pressure on public finances, has itself resulted in spiralling costs because of the pressure on the national NHP team to produce construction savings though standardised design which has resulted in lengthy delays. The pledge to fund 40 hospital schemes simultaneously may ratchet up the cost to the Treasury further if the number of construction companies willing and able to participate is limited relative to the number of schemes that need to be built, placing construction companies at a market advantage. It would be interesting to compare the scale of the additional costs caused by the delays and the scale of the savings made by taking time to develop Hospital 2.0, which the national NHP team believes will lead to a 25% reduction on building cost. Since the big cost and time savings associated with Hospital 2.0 are expected to be fully realised only for cohort 4 schemes onwards, the Leicester scheme like others in cohort 3 suffers the additional cost and delay disadvantages of Hospital 2.0 without reaping the full financial benefits.
- The ‘Minimal Viable Product’ (MVP) is a particularly ominous development given the tendency in recent decades to build hospitals which are too small to meet local need in order to hold costs down. This has resulted in inadequate hospital capacity, contributing to rising waiting lists even before the pandemic, a severe impact on the workload and morale (and retention) of staff and additional pressure in primary care. I do not know what the MVP consists of but patient flow and pandemic proofing both require the availability of redundant capacity at any given point in time. The concept of minimal viable product appears to militate against this. There is a danger that investment needed now to reduce carbon emissions will be stinted on as net zero carbon requirement is not an immediate one when in fact daily reminders of climate heating underscore the importance of action sooner rather than later. There is a risk that HM Treasury will put pressure on Integrated Care Systems and Trusts to sign up to the MVP with short-term considerations outweighing more rational, longer-term planning.
- A widespread but mistaken belief that the English health service had too many hospitals, and national pressure over many years to reduce the bed base, along with severely constrained finances, gave rise to a local track record of optimism bias in planning with unrealistic assumptions (about efficiencies, amount of care which can be transferred to community settings etc.) underpinning unrealistic plans for hospital provision. Locally, this was seen in the Better Care Together Strategic Outline Case in 2014, the Sustainability and Transformation Plan in 2016 and again the Building Better Hospitals For the Future pre-consultation business case in 2020. The National Audit Office report on the New Hospital Building programme suggests that the same mistakes could well be made again, undermining value for money and with damaging long term consequences for patients and an overwhelmed workforce.
- Cohort 3 schemes, including the Leicestershire and Rutland scheme, are likely to bear the brunt of the difficulties and snags which arise in any new approach but without reaping all of the cost saving benefits, as they will be the first to be required to adopt the Hospital 2.0 model. At present there is little in the public domain about the Minimal Viable Product and its associated risks and there are no public discussions taking place locally about any of these matters.