A real Accident & Emergency Department must have a genuine 24/7 consultant delivered surgical and medical service. For a start it must meet the Royal College of Physicians guidelines so that a consultant physician should always be available ‘on call’ and should be on site at least 12 hours per day, seven days per week with no concurrent duties. And the admissions unit should have a consultant presence for more than four hours per day, seven days per week doing two rounds per day. That alone rules out around half the current “A&E”s. Then add the surgical capability to deal with the vast majority of cases and then the need for 24/7 diagnostics. In reality we have lots of places claiming to be A&E which are unsafe and unsuitable; many so called A&Es are actually already Urgent Care Centres.
And the answer is not spending more money to upgrade those which don’t meet the standards. Aside from how you pay for it there simply are not enough clinicians, nurses and diagnostic staff to go round. To be able to justify the high fixed cost of a true A&E and to provide a sufficient volume of patients to justify having 24/7 cover across almost all specialities requires a certain population level. Whilst this is a subject for some debate most think that population is at least 1m, probably more.
Given the needs of rural areas some kind of hub and spoke model has to be obvious, where some patients go to, or are taken to, a local spoke; part of an emergency care system. The spokes can deal with the immediate needs in any type of emergency in any age group with cover from emergency care doctors 24/7 but may not have full on-site back-up services. A minority of patients may have initial treatment at a spoke and then be transferred using agreed protocols and procedures. Many “A&E”s do not even meet this lower standard.
Despite widespread opposition we already have systems where some patients (such as those with severe trauma or stroke) go direct to a regional or sub-regional unit where possible, or else go to a more local unit for stabilisation before onward transfer. The evidence shows that going to the right place is better than going to the nearest place.
You then move to the next problem of what to do with some District General Hospitals if they no longer have A&E. And that is the real issue – what is the best configuration for acute care and how do we get there from where we are today. But politically we can’t have that debate and the Royal Colleges are not giving us the leadership, at least not yet.
So “downgrade” an “A&E” and protests follow. It is claimed, always, that lives are put at risk if a local “A&E” is closed and the ambulance has to travel further. If anyone tries to point out there is less risk overall then they are shouted down. This just reflects the sad truth that for many years the NHS leadership has totally failed to explain reality and everyone thinks closure = cuts; and it often does! Maybe the time to rationalise our emergency care was when funding was less of an issue.
The Department of Health fall back on the nonsense that “Changes to local health services are decided and led locally. Local healthcare organisations, doctors, nurses and other health professionals, with their knowledge of the patients they serve, are best placed to decide what services they need for patients in their area.” This is so ludicrous they should have noticed. Just about every contentious proposal actually gets referred up to the Independent Reconfiguration Panel and so to the Secretary of State – so hardly local. Most proposals actually cover various “localities” not just one and there is unlikely to be a “local” voice with any clarity. The classic is where everyone agrees one of two units must shut and services concentrated in one place – for perfectly sound reasons. But which “locality” loses its service? Where is the leadership then?
The whole problem is compounded by the wider mess we have made of what should be a coherent urgent/emergency care system. Most urgent care is primary care, but we don’t invest in primary care. We failed to give the ambulance services the key role they merit and instead fragmented the system using competition for lots of urgent care providers and out of hours GP services and it’s an uncoordinated and confusing mess with ridiculous duplication of systems and processes.
So it’s easiest to get out the placards, join the protests and defend local services. See you at the barricades.
Irwin Brown
