Briefing Note: Why We Defend BOTH Our A&E Departments

Well, we’ve got nothing to worry about. Secretary of State for Health Jeremy Hunt visited Telford in February 2014 and was challenged about the possible closure of one of our two local A&E Departments. Jeremy Hunt said, “We commit to A&E on both sites and there are no plans to change that.” So there you have it. We can sleep easy in our beds.

If this is true, the fears for our A&Es – and the hospitals that go with them – are easily solved. The Chief Executives of the acute hospital trust and of the Clinical Commissioning Groups that buy services can make a straightforward commitment. They can pledge that there will be no closure or downgrading of the A&E departments at Telford or Shrewsbury, and no closure or downgrading of the Princess Royal Hospital or the Royal Shrewsbury Hospital.

What’s Really Happening

Away from the ‘everything’s fine’ world of Jeremy Hunt, we’re heading quickly for the loss of an A&E department. We currently have two A&Es: one at the Royal Shrewsbury Hospital, and the other at the Princess Royal Hospital, in Telford. Back in August 2013, Peter Herring – Chief Executive of both hospitals – said that one of the A&Es was likely to close, and that ‘providing specialist health services, including accident and emergency and intensive care, at both hospitals was unrealistic’. The acute trust (the organisation running the two hospitals) is in financial crisis. They’ve just been bailed out to the tune of £4 million by the NHS nationally, because they ended the financial year in serious deficit. Closing down an A&E – or even better, one of your District General Hospitals – is a great way of saving a lot of money.

The organisations that buy NHS care for local people are called ‘Clinical Commissioning Groups’ or ‘CCGs’. We have two of these: Shropshire CCG and Telford and Wrekin CCG. They’re short of money too. Back in August 2013, Caron Morton – Chief Executive of the Shropshire CCG – told a Board meeting that there was an £82 million ‘financial gap’ across the local healthcare economy. Her estimate was that two CCGs between them, and the organisations they buy healthcare from, were likely to be short of at least £82 million by 2017/18. It’s no surprise that the two CCGs want to close one of the A&Es. Again, it’s a very effective way of saving cash. This is an agenda driven by cuts, not by patient care.

It’s worth making the point that local NHS bosses are just passing on the cuts; it’s not really their fault. There are £20 billion ‘efficiency savings’ already happening in the NHS nationally, and the government has decided to starve the NHS of funds year on year to create a planned and deliberate shortfall of £30 billion by 2020. Privatisation and reorganisation are also stripping out huge amounts of money. Cuts on this kind of scale will pretty much wipe out the NHS. It would be nice if NHS bosses came clean on this, but their jobs depend on an elaborate pretence that everything’s OK.

The national cuts programme is called ‘Call to Action’. This is essentially about planning for the £30 billion shortfall. The local version of ‘Call to Action’ is known as ‘Future Fit’. This is the NHS cuts programme across Shropshire and Telford and Wrekin. The initial Future Fit programme plan is a poorly thought out document that chucks in some NHS management wiffle waffle and pretends to be a strategic document. It isn’t. It’s a cuts document. It also takes us in a very different direction to some of the good national guidance now emerging around urgent and emergency care.

‘Future Fit’ is almost certainly about closing one of the two A&Es. You have to do a little bit of reading between the lines, but not too much! Alarmingly, the February 2014 document  states ‘Most pressingly, the Acute Trust currently runs two full A&E departments and does not have a consultant delivered service 16 hours/day 7 days a week’.  It might make more sense to invest properly in the two A&E departments, but this is left unsaid. In practice this is code for ‘We want to close an A&E’.  By March 2014, the plan is emerging more clearly. The acute trust had an update on Future Fit at its 27th March Board meeting, and was told, ‘The preferred model is therefore for a single, fully equipped and staffed high acuity emergency centre…’. David Evans, Chief Executive of Telford and Wrekin CCG, has independently confirmed that the intention is to have ‘one centre of emergency care’.

It’s actually worse than this. Once you close down an A&E department, this rips the heart out of a hospital. Our two acute hospitals currently both have intensive care units, and this means that both are able deal with acutely ill patients, carry out complex surgery, and deal with higher risk maternity cases. A lot of intensive care admissions will come straight from A&E, though, and that means that the intensive care unit will be closed when the A&E is closed. The anaesthetic service is also very much at risk. So when the A&E is closed, a District General Hospital effectively gets downgraded. It loses a whole raft of services, and in practice becomes a large community hospital rather than an acute hospital.

This will almost certainly happen as part of Future Fit. Back in November 2013, Caron Morton told a ‘Call to Action’ event that there was a lot of ‘duplication’ involved in running services across two hospital sites, and we had to start thinking about a single hospital trust instead of two hospitals. This is echoed in the Future Fit planning document. We’re told Opportunity costs in quality of service – In Shropshire and Telford and Wrekin the inherited pattern of services, especially hospital services, across multiple sites means that services are struggling to avoid fragmentation and are incurring additional costs of duplication and additional pressures in funding’ (their emphasis). The financial agenda is clear. This isn’t about patient care. It’s an obvious point, but it isn’t ‘duplication’ to be able to access healthcare at your local hospital.

The loss of an acute hospital can happen by stealth, and it’s overwhelmingly likely that this is already taking place. Telford councillors, to their absolute credit, have been vocal in their defence of the Princess Royal A&E. Shropshire councillors seems to be very busy with cuts and privatisation, and have remained silent. Shrewsbury is therefore emerging as a softer option for closure. It appears that Royal Shrewsbury A&E is most at risk, and Royal Shrewsbury Hospital is already being run down. Stroke services have already moved from the Royal Shrewsbury to the Princess Royal. Consultant-led maternity, women’s and children’s inpatient services are currently being moved from the Royal Shrewsbury to the Princess Royal. There were plans for an outpatient ‘Children’s Zone’ and a ‘Women’s Zone’ at Shrewsbury. These are now on hold ‘pending the outcome of the Future Fit programme and an understanding of the impact this will have on the RSH site’ (Report to Shrewsbury and Telford Hospital Trust Board, 27th March 2014). It could be that Future Fit will call for serious re-investment in clinical services at the Royal Shrewsbury – but this is certainly not the direction of travel.

The Danger of Divide and Rule

It’s easiest to push through NHS cuts and closures by dividing people – by trying to trick people into saying ‘Keep our A&E, and close theirs instead’. This campaign completely rejects this approach. In our launch press release we said, ‘It looks like Shrewsbury Hospital is already being run down, in preparation for closing the A&E. It doesn’t matter which way round it is, though: Shrewsbury or Telford. If you close either A&E, we all lose out. A lot of us will travel further for emergency care, the A&E that stays is completely over-loaded, and one of our hospitals gets run down and closed. Our campaign is committed to defending both A&Es and both our hospitals, as well as making sure we’ve got decent community NHS services across the county. We’re opposed to privatising the NHS too. We want an NHS that’s there for patients, not for big business’. Defence of both A&Es and both hospitals is the only principled approach, and we stand by it one hundred per cent.

Will There Be a New Hospital and a New ‘Super-A&E’?

As a sweetener for the plans to close an A&E, they’ve suddenly come up with the suggestion that there might be a new hospital attached to a new ‘super-A&E’.

Could this happen? It’s actually very unlikely. The Future Fit programme document makes it clear that this would be subject to the availability of capital funding, and this is unlikely to be available in an NHS that is trying to make £50 billion worth of cuts. The only commitment in Future Fit is that this will be included in ‘any long-list of future options’. David Evans, Chief Executive of Telford and Wrekin CCG, said, ‘If we have a fair wind and the money is there, it could happen by 2018-19’. There’s not a lot of certainty here!

Even if there were to be a new ‘super’ A&E, this does not overcome the problems inherent in longer journey times. And any new hospital would probably end up being built through PFI or one of its variants, with genuinely serious consequences for the funding of other healthcare.

Are Campaigners Opposed to Change?

No, of course not. Healthcare evolves and changes all the time. This is fine, so long as the agenda is one of creating better patient care. There’s nothing wrong with efficiency, either – so long as this isn’t about damaging patient care.

There’s a lot of discussion nationally on how the NHS could develop. There are ideas about prevention of acute illness, looking after people better closer to their homes, and developing specialist emergency care centres to treat some patients more effectively. Some of the ideas are very good. There’s a positive new report on urgent and emergency care by a doctor called Professor Bruce Keogh, the Medical Director of NHS England, as well as relevant papers from the King’s Fund and the Nuffield Trust.

Prevention is a key idea. It makes sense to avoid people having to visit an A&E in the first place if possible, and to keep people out of hospital if possible. If you have really well designed and properly funded community NHS services, backed up by high quality social care, this will reduce A&E visits and hospital admissions. This is really important in looking after people with long-term conditions, and in the care of older people.

For example, a large number of A&E visits are by older people with a urinary tract infection. A UTI will often get better by itself, or will resolve after a GP visit and a short course of antibiotics. For some people, a UTI is a much bigger problem. In frail older people, a urinary tract infection will sometimes cause acute confusion, with the loss of skills and a risk of falls. People can end up very unwell, attending A&E, and often requiring subsequent hospital admission. The solution is make sure that people can get same-day GP appointments, with home visits readily available when needed; that good district nursing services are there for those who need them; that patients and carers are educated on the risks of UTIs; and that there is high quality social care to ensure that the frailest people don’t slip through the net in a crisis. If all of these things are in place, a whole chunk of patients will be picked up before they are acutely unwell. They won’t need an A&E visit, and won’t need hospital admission.

A&Es see a large number of patients who self-harm. The need is for high quality community-based mental health services to stop people sliding into crisis; a responsive community-based crisis service when people need that extra support; timely and supportive GP care; and enough specialist in-patient beds that people with mental health problems can get a high level of care when they really need it. If all of these things are in place, another category of A&E admissions will sharply reduce. (Sadly, mental health care continues to be a ‘Cinderella service’).

Some of the research around the connections between different strands of care is fascinating. There’s one study that showed that if you provide one extra GP per 10,000 people, you reduce mortality by 6%! There’s another study where a GP practice reorganised home visits to provide home visits more readily and earlier in the day – and in the process reduced emergency hospital admissions by 30%.

There’s a strong move towards caring for people closer to home. Absolutely fine. This makes sense clinically if (but only if) the right services are in place. There’s a lot of games playing with this one, though. There’s a pretence that community NHS services are automatically cheaper, although there’s actually no robust evidence that this is the case. There’s also a pretence that community-based NHS services are adequate when very clearly they are not. For example, the Shropshire CCG website tells us that we should only attend A&E if we have ‘emergency medical conditions or trauma that threatens life and limb’ – but the web page sends us off instead to Minor Injury Units that are not open in the evenings or at weekends. One, the Whitchurch Minor Injuries Unit, is only open from 9.00 am to 5.00 pm on weekdays. Don’t get sick out of hours! Even more bizarrely, the Shropshire CCG has just decided that Minor Injuries Units will no longer get paid for seeing sick people; in a change of use, they’re for ‘minor injuries’ and nothing else. How on earth are patients supposed to know where they can be treated, when the CCG cuts costs, moves the goalposts and doesn’t tell anyone? The alternative suggested by the CCG is ‘NHS 111’ – the computer-driven system with an early history of failure. We have a confusing and inadequate system. (Sadly, Future Fit does not include any properly considered proposals for urgent care).

It’s increasingly recognised that some medical emergencies are best treated in specialist A&E units, where there’s likely to be a specialist team with expert skills. This is true for major trauma, for example, and for stroke care. For some emergency patients, it’s accepted now that it makes sense to drive past the local A&E and go on a little bit further to a specialist centre (or to stabilise them first at the local A&E and then transfer to a specialist centre). Specialist care for those who need it is of course a good thing. For other emergency patients, longer journeys to A&E are catastrophic. For patients with severe respiratory problems, for example, every moment counts. Longer journeys increase the chance of irreversible brain damage or death.

The research confirms that patients who travel a longer distance to A&E are more likely to die. The most important large-scale study showed an overall 5.8% mortality rate for patients travelling a straight line 0 to 10 km distance to A&E, for example, but an 8.8 % mortality rate for those travelling 21 to 58 km. The effect was most pronounced in patients with respiratory conditions.

If They Close an A&E, Does it Matter?

Yes!

The major users of healthcare are children and older people. That means the local NHS faces a double whammy of demand, with a relatively young population in Telford and Wrekin, and a proportion of older people way above the national average in Shropshire.

Much of the patch is rural, in Shropshire and across into Wales. South West Shropshire already has the longest travel distances and times to acute hospitals in England.

Shropshire CCG already spends less than national average on acute hospitals.

Our ambulance response times are already failing to meet national targets.

Is it really in our interests to travel further, with more strain on under-funded ambulance services? Is it in our interests to spend less on acute hospital care without a cast-iron guarantee that high quality alternative care will be in place before any cuts and closures?

Local NHS bosses want to close an A&E and run down one of the District General Hospitals. The agenda is cutting costs. These are supposedly just ‘options’ pending public consultation next year, but the direction of travel is clear. The Future Fit proposals are contradictory and short-sighted, and fall far short of the national guidance in the recent ‘Urgent and Emergency Care Review’ led by Professor Keogh.

Any considered and intelligent approach to NHS reform would look carefully at how to create an integrated system of care: at patient education, phone support, out of hours pharmacy cover, GP provision (including same day access and home visit availability), at our ambulance services, at the whole network of community NHS services, mental health services and social care. These things need to be looked at in Shropshire, Telford and Wrekin, and across the border into Wales. Future Fit makes no attempt to do these things. It’s a ‘quick and dirty’ approach, and it’s about saving money. The pretence around patient care is just that: a pretence. Patients are not being put first.

We’ve got a general election not so far away. Jeremy Hunt has already come to Telford to promise that neither A&E will close down. It’s going to be a good year for People Power! Across England, campaigns to defend A&E departments and NHS services are proving successful. Our job is to make sure we succeed in Shropshire and Telford and Wrekin.

Shropshire Defend Our NHS
3rd April 2014

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