Curiouser & Curiouser in NHS Lanarkshire

Elaine Smith MSP

I have often felt like Alice in Wonderland since being elected to the Scottish Parliament but never more so than on Monday August 21 when NHS Lanarkshire's decision to downgrade Monklands hospital to a level 2 status was ratified by the Scottish Executive; a decision which was, coincidently, authored by another well known Lewis.

Monklands General Hospital serves over half of the population of Lanarkshire, some 230,000 people, with the remaining populace served by Wishaw & Hairmyres. It is little surprise then that, based on patient attendance and admissions, as well as, hours lost to GP referrals, Monklands is home to the busiest and most efficient A&E in the area.

The people of Lanarkshire, particularly in the Monklands/Wishaw area, suffer from some of the poorest health in Scotland. The gap between their health and that of the rest of Scotland is considerable and has remained stubbornly pronounced in recent decades. This is undoubtedly linked to the fact that Monklands also has some of the highest levels of poverty and deprivation in Scotland.

To put this in a context that even Tweedledum and Tweedledee would grasp; if there was not a level 3 general hospital situated within Monklands & the surrounding area we would undoubtedly be seeking to build one. That need was very firmly recognised by the late James Dempsey MP, a Labour representative, who fought for the establishment of Monklands General Hospital some 30 years ago against a backdrop which saw Glasgow Royal Infirmary apparently operating at 150% capacity prior to Monklands' opening in 1977.

So how can a decision, made by 'men in suits'; most of whom, to hazard a guess, do not reside in Monklands, to downgrade a vital hospital in an area of acute deprivation and ill health, be ratified? That question returns us to where I started; curiouser & curiouser.

Having carried out a 3-month 'consultation' exercise on 'A Picture of Health', NHS Lanarkshire then proceeded to unashamedly ignore the submissions received, the 50,000 signatures and the comments at public meetings: all in favour of retaining Monklands level 3 status. The cavalier attitude of the board was vividly illustrated by the meagre 6 week turnaround between the final consultation closing date and the health board's final decision. Further evidence, if any was needed, of NHS Lanarkshire's determination to bulldoze through it plans could be seen in the four hour long meeting in which its decision was made; a meeting which, if confined to actual debate of the issues, would have barely lasted forty five minutes.

The whole thrust of the exercise was a blatant attempt by NHS Lanarkshire to make a case for their 'clear preferred option' of downgrading Monklands hospital from a level 3 to a level 2; a preference they identified prior to beginning their consultation.

The reasoning behind this predilection is a mystery since most of the board's own research information actually demonstrated the considerable benefits for patients' right across Lanarkshire of retaining level 3 ranking for Monklands. Therefore, it has to be assumed that factors other than health improvement and balanced service provision are at play; with the most obvious being the PFI status of Wishaw and Hairmyres and the myriad of contracts which bind the operation of those hospitals.

The board maintained that the agenda was being driven by the need to ensure the delivery of a safe and effective service in the face of considerable operational changes such as the European Working Time Directive, reductions in junior doctor's working hours and changing shift patterns, alongside a chronic lack of consultant expertise in some disciplines.

They also said that they intended to continue operating three general hospitals; one a planned care centre (level 2) and two remaining as level 3 incorporating A&E. To progress this agenda their 'option appraisal exercise' was undertaken; an exercise highly questionable in its impartiality and criteria base. Only two options were put out for 'consultation'. The status quo was discounted as being unsustainable after 2009 and Wishaw was shielded from downgrade primarily because it houses the only maternity unit in Lanarkshire. Rather than consult then on a level playing field between Hairmyres and Monklands, the latter was earmarked as the "clear preferred option" for downgrade, despite the failure of the appraisal exercise to identify any "clear" frontrunner.

Such a decision appears highly illogical; corrupting from the outset any notion that this would be an 'open' consultation; alienating and marginalising patients who understandably believed that a decision had already been made and suggesting, against all measured reason, that the busiest, most efficient and most effective A&E in Lanarkshire serving the densest population was somehow surplus to requirements.
It is quite clear that in recommending Monklands Hospital for downgrade, a financial agenda has been promoted before the health and social needs of the people of Lanarkshire. I believe that the financial basis for the boards decision was skewed to reflect the preferred option and this, added to the fact that no thro' life costings were worked out, means that the board may have broken Treasury guidelines. I have therefore asked the Auditor General to consider this matter.

The downgrading of Monklands will add to the social exclusion experienced by the most deprived residents of my community. As many of the services currently established in Monklands will move to Wishaw or Hairmyres, the parents, visitors and carers of patients accessing these services will now have to make the journey across Lanarkshire to visit their loved ones. Those individuals without access to a car, as much as 52 % of the population in some areas of Coatbridge, will be significantly disadvantaged. Also, despite assurances to the contrary during the consultation, it now seems that planned care will be retained at both Hairmyres and Wishaw; thus making a mockery of all the arguments used to justify the reconfiguration of planned and emergency care and potentially ensuring the future 'cottage hospital' status of Monklands.

If difficult decisions must be made to ensure safe service delivery and better health outcomes then they must be made in a way that reflects the fundamental principles of the NHS and be sufficiently weighted for their impact on reducing social and health inequalities. The decision of NHS Lanarkshire flies in the face of this responsibility and puts at risk the health and the lives of some of the most vulnerable people in Lanarkshire and, indeed, in Scotland. It is an outrage that these people may end up paying the ultimate price in health terms to underwrite NHS Lanarkshire's debt to private profiteers under PFI deals.

Returning once more to Alice perhaps we can find the answer as to why an erroneous, absurd and downright dangerous decision has been upheld, in an exchange between the previously mentioned Tweedledum & Tweedledee ; 'I know what you're thinking about,' said Tweedledum; `but it isn't so, nohow.' Contrariwise,' continued Tweedledee, `if it was so, it might be; and if it were so, it would be; but as it isn't, it ain't. That's logic.'

This article first appeared in Holyrood Magazine in October 2006