These questions were distributed to Liverpool City Councillors on 30 Jan. Richie Krueger, fresh from the Maghull battle against plans for a privatised GP surgery, addressed the full Council meeting for KONP Merseyside.

Questions you should ask about the proposed redevelopment of the Royal Liverpool and Broadgreen hospitals

1) PFI: The Council must be aware of the disastrous catalogue of Private Finance Initiative (PFI) schemes dragging NHS Trusts into debt around Britain – for example Coventry and Manchester – and PFI hospitals with wards full to bursting point – for example Norwich, Worcestershire.

• Why should Liverpool choose to repeat these common experiences with PFI rather than demand Public Finance for any required capital expenditure on hospital refurbishment or redevelopment?

2) Cuts: The Clinical Service Delivery Model (CSDM) of October 2007 for the Royal Liverpool and Broadgreen University Hospitals NHS Trust refers to PCT initiatives intended to reduce admissions to hospital, and the projected demand in 2014/15 is adjusted downwards. No evidence is given for the very specific numbers of reduced admissions to hospital, and there is no assessment of the risk of failing to achieve these targets by 2014.

• Why should hospital capacity be reduced without hard evidence that the PCT Initiatives will actually deliver as projected?
• If the evidence exists, why hasn’t it been published?
• What happens if hospital capacity is reduced but the PCT Initiatives fail to reduce demand as projected?

3) Emergency: The CSDM Section 8 (ii) states: “The annual underlying growth in the new emergency attendances has been assumed at an overall rate of 0. 9% from 2006-07 onwards. This contrasts markedly with the actual growth in the three years from 2004-05 to 2006-07 when annual growth averaged 4. 0%. The Trust and PCT are working collaboratively to ensure that these reduced levels of growth can be achieved.”

• If their efforts are not currently reducing growth, why assume they will do so in future?

The 2005-6 agreed baseline for the Emergency Dept is shown as 93, 567 but the figures for 2006-7 in the 1 May 2007 Performance Report show A&E new attendances were 119, 980 for Apr 06 – Mar 07.

• Is the baseline wrong, or was there a 28% increase in 1 year?

4) Emergency: The PCT Initiatives include, under “Other Admission Avoidance”:

* reduce emergency admission from Care homes

* “frequent flyers” – eliminate 4th and subsequent readmissions for emergency medicine for patients with 4 or more emergency readmissions.

• What will happen to Care home residents who currently attend Emergency?
• What will happen to patients with 4 emergency admissions?

5) Outpatients: CSDM Section 8 (iii) shows a reduction of 59, 787 follow-up attendances due to a “Reduction in follow up ratio” and states “The elective model assumes a 20% reduction in the first to follow up rate for all PbR [Payment by Results] specialties and in the PbR exclusions of Restorative Dentistry to take account of a shift to more one stop clinics and more long term management being carried out in the community.”

• What evidence is there that a 20% reduction can be achieved?
• What will happen to outpatients who want follow-up appointments in hospital?

6) Surgery: CSDM Section 9 (iii) shows a reduction from 9 to 6 theatres for planned surgery in the Royal. The plan assumes an 80% utilisation rate for surgical theatres.

• What is the current utilisation rate?
• What evidence is there that utilisation at the Royal can rise to 80%?
• What allowance is made for fluctuating demand, theatre maintenance, or contingencies if 3 theatres are lost?

7) Surgery: The Trust has employed the consultancy firm KM&T (Knowledge, Management & Transfer) to advise on surgery. KM&T describe themselves as experts in LEAN (Toyota Production System) methods: “KM&T has years of experience within a diverse range of sectors to deploy Lean Thinking. This experience, coupled with our Toyota background, has enabled KM&T to successfully assist the NHS and healthcare community”.

• Why should methods pioneered by Toyota for auto production be adopted by surgeons operating on people?

8) PFI: Recent detailed research “Private finance, public deficits” by Mark Hellowell and Allyson Pollock of the Centre for International Public Health Policy at the University of Edinburgh, based on systematic Freedom of Information requests to the Dept. of Health, has shown that “Trusts with operational PFI schemes with capital values of over £50m have average capital costs of 10. 2% [per annum] – a shortfall in income of 4.4%”. This shortfall is the gap between 10.2% capital costs and the 5.8% of trust income assigned to capital costs under Payment by Results. PFI schemes entail service cuts before operation begins, and the shortfall then causes a new round of cuts once the scheme is operational. Trusts are legally obliged to pay annual PFI capital costs as their first priority, even above clinical need.

• How do the Trust plan to meet an annual shortfall of 4.4%, which must be anticipated from the existing experience of large PFI schemes?

9) PFI:

• What discount rates will be applied to the PFI proposals and to the Public Sector Comparator in assessing Value for Money?