Shropshire NHS chief executives have warned there could be times when there are not enough doctors to cover all departments at the county’s two main hospitals.

It is becoming increasingly difficult, they claim, to ensure the “right people with the right skills are always in the right place”.

They say they are aiming to begin a “new conversation” about how to best respond to some serious quality and safety concerns emerging at the Royal Shrewsbury and Telford’s Princess Royal.

The chief executives have also raised the spectre of services being lost to hospitals outside Shropshire – a worry highlighted by former hospital boss Tom Taylor.

“We believe there is much to be proud of about the strengths of healthcare in our two hospitals,” they say.

But they warn: “We are worried that, without some changes, standards will start to slip. We will also face questions about whether it is right to provide such services if we cannot do so safely into the future.

“We are confident that with the right configuration we can continue to build for the future rather than feel concerned about which services might be lost.”

The trio – Adam Cairns from the Shrewsbury and Telford Hospital Trust, Jo Chambers of the Shropshire County Primary Care Trust and Simon Conolly from NHS Telford and Wrekin – cite two reasons why problems are getting worse.

In an introduction to a discussion document they say the training programme for doctors who become specialists is now shorter than it used to be.

Historically, for example, a general surgeon might have carried out large volumes of abdominal, breast and vascular surgery while in training.

Today consultants will have specialised in one of these branches of surgery much sooner and will therefore not have the skills to perform techniques they have not been trained to deliver.

Secondly the number of doctors who can be recruited to the two hospitals, fluctuates. “This could lead to occasions when there are not enough doctors to cover all the departments in the hospitals,” say the chief executives.

“This is happening partly because doctors can choose where to work and some are deciding not to come to our hospitals because of the problems described. We have also experienced a reduction in the availability of some doctors from overseas who have in the past been able to help.

“The consequence of this could be that too few doctors are left trying to look after too many patients.”

The chief executives say they are clear there are some “fixed points” which need to be maintained. These include:

* Ensuring there are two vibrant, well balanced and successful hospitals, with both playing a full role.
* Commitment to an A&E department on both sites.
* Ensuring there is access to emergency general surgery from both hospitals.

But they add: “Everyone recognises that all of the commitments will need to be tested for affordability and deliverability.”

During a workshop to examine changing the way services are delivered, two focus groups considered a range of options relating to acute surgery and children’s services. The acute surgery group felt that “no change” was not an option.

Also bringing acute surgery together in a new hospital between Shrewsbury and Telford was not feasible because it would cost “many hundreds of millions of pounds” which is not affordable currently, or in the foreseeable future.

Having each hospital focusing on a particular type of surgery was a “feasible scenario” as long as the trust worked together as a single organisation with all clinical departments integrated.

Service commissioners would need to recognise the hospital trust as the provider of services, rather than the individual hospital sites. Transport issues would also have to be addressed.

It is claimed the infrastructure of each hospital could support such changes with minimal capital investment.

The Princess Royal, it is suggested, could be responsible for breast, urological, vascular and orthopaedic (routine and emergency) surgery, and could also deal with major non life-threatening trauma, minor trauma, and medicine.

At the Royal Shrewsbury there would be colorectal, upper gastro-intestinal and orthopaedic (mainly emergency, including multiple injuries) surgery. It would also deal with major life-threatening trauma, minor trauma and medicine.

Such a move, it is claimed, would produced two well-balanced­ sites providing a wide range of surgical services, and ending unnecessary duplication.

A “credible” A&E would continue at both hospitals.

Rotation of medical staff between the two sites would help to maintain skills and interest, and equalise workloads.

The children’s services focus group also felt that “no change” was not an option.

It has suggested one hospital – not named – would have children’s outpatient services, a 24-hour paediatric assessment area, inpatient beds, special care baby unit, and consultant-led maternity services with co-located midwife led maternity facilities.

The second hospital would have children’s outpatients services, an 8am to 10pm paediatric assessment area, and midwife-led maternity services.

This idea ensures paediatrics, including day case surgery, is retained at both sites.

“Compared to the current service, the same care in the same place will be available for the majority of children, as few children require overnight admission to a local general hospital,” says a report.

“The main difference will be for families whose child is admitted. This model presents an option for maintaining safe and sustainable inpatient children’s services, linked to the wider clinical challenges facing the county.”

Another model would see paediatric medical overnight beds maintained at both sites. But there would be a continuing need for two middle grade staff rotas, which does not address current pressures on rotas.

Also the trust might not be able to maintain the vital role of educating doctors in training.

Last year a set of proposed changes to the way services are delivered at the two hospitals met strong opposition, mainly in Telford & Wrekin where there were fears the Princess Royal would be downgraded.

The workshop report says: “We recognise we did not get the process right last year. And,if we don’t get the process right, then we cannot reach the best possible solution that will ensure safe and sustainable services, whilst commanding the confidence of patients, and of clinicians.

“Decisions about the shape of NHS services must be made through an open and transparent process.”

Firm proposals are expected early in the New Year and will be consulted on until March or April.

The Government has set four tests which must be met before any service reconfiguration can take place.

Proposals must show that they are underpinned by clear clinical evidence, demonstrate support from those who commission services, strengthen public and patient engagement, and support patient choice.