Controversial plans to overhaul emergency medical care have been put on hold after NHS bosses were warned that downsizing A&E units would create a huge backlash.
NHS England has delayed its plans following claims by insiders that concentrating specialist services into just 40-70 hospitals would represent “political suicide” so close to the general election.
The plan to streamline the role of A&E units across England was outlined last November by its medical director, Sir Bruce Keogh. He said the move was needed to save lives and it was an “illusion that all A&Es are equally able to deal with anything that comes through their doors”.
Up to 70 A&Es were to be designated as “major emergency centres” to look after the most critically ill patients – victims of strokes, heart attacks or trauma – leaving the rest of the 225 A&Es to deal with the less seriously ill.
But an insider involved in the process said: “All his talk about reconfiguring emergency departments, abut splitting them into supercentres and other ones, has died a death.”
Keogh said advances in medical science meant that a minority of hospitals needed to have the specialist doctors and equipment required to maximise the chance of saving patients facing life-threatening illnesses.
The first systematic review of emergency care since the 1970s was necessary, he claimed, because the ageing population was changing the nature of the illnesses A&E units were expected to tackle. The review should be accompanied by an honest debate about how to improve emergency care, he added.
Emphasising that the “future vision” of A&E care had been drawn up by doctors seeking the best outcomes for patients, Keogh said: “There will be between 40 and 70 major emergency centres but they will be connected as part of a network to smaller emergency centres who will still be receiving the majority of ambulances. By passing patients with acute conditions on to the specialist centres, we can decongest smaller A&E units so they have more capacity”.
Jeremy Hunt, the health secretary, said that ministers would back the implementation of Keogh’s review. Reorganising A&E services which the public value dearly would show the coalition was “a government that is prepared to face up to the difficult decisions”, Hunt said.
But the planned shakeup is not mentioned in a 13-page document setting out the most recent update on the planned transformation of urgent and emergency care services, which NHS England circulated in August but did not publicise. It says that the review’s report last November “recognised the appetite for change but emphasised that there will be no risky ‘big bangs’”.
Insiders involved in the review say NHS England has been warned that introducing what amounts to a two-tier A&E system will prompt opposition, including from MPs and councillors, in areas where the local hospital could be seen as being downgraded if it did not become one of the 40-70 major emergency centres.
Chief executives of major NHS hospital trusts privately expressed their opposition, with some concerned that it could lead to a loss of vital income.
Keogh’s denial last year as “categorically not true” that the smaller A&E units would be allowed to “wither on the vine” did not allay fears that some would ultimately close.
The College of Emergency Medicine, which represents A&E doctors, said it never believed that the massive centralisation of services was justified clinically.
Dr Cliff Mann, its president, said: “In my view, the urgent and emergency care review started from an erroneous premise that the system that has been applied with some success to the treatment of heart attack, stroke and major trauma could be applied to many more conditions and hence ‘regionalisation’ of major centres was a likely outcome.
“It has become evident from evidence submitted to the review that fewer than 4% of A&E attendances might derive any benefit from such a reconfiguration. Importantly, such a system works well only for severe conditions requiring very specialist services where the diagnosis can be made before the patient even reaches hospital. It is easy to spot when someone has been hit by a bus, fairly easy to spot the classic signs of a stroke and all ambulances carry machines capable of diagnosing an acute heart attack.”
Meanwhile, the Care Quality Commission says it has found problems in about half of all A&E units it has inspected.
The most common problems the NHS care watchdog found were: understaffing; ambulances waiting a long time outside the A&E unit because patient flow through the hospital is slow; delays to patients undergoing diagnostic tests such as x-rays and MRI scans; and management of medicines.
Prof Sir Mike Richards, the CQC’s chief inspector of hospitals, said the high number of A&Es classed as “inadequate” or “requires improvement” was partly because inspectors using the regulator’s more inquisitive new approach had prioritised visiting hospitals where there was concern.
Despite the prevalence of poor care, the A&E units at Frimley Park hospital in Surrey and the Homerton hospital in east London were both found to be “outstanding”, Richards said.
Prof Keith Willett, NHS England’s director for acute episodes of care,said: “There is absolutely no question of slowing down on the review. It is a central part of the NHS five-year forward view and the pace is about to accelerate. Sorting out the urgent care system is one of the most important priorities for the public and for the NHS.
“The heavy lifting starts in 2015-16, which will include the formation of urgent care networks to include all hospitals with A&E departments across England. We expect networks to identify the 4070 emergency centres which have specialist services.”
• This article was amended on 1 December to include Willett’s comments on the emergency care review.
Professor Willett has spent his entire career treating complex fractures. He was Professor of Orthopaedic Trauma Surgery in the University of Oxford. One has to wonder what bearing his experience has on the treatment of Acute Asthma, Anaphylactic Shock, and Appendicitis (the "Three A's" of Emergency Medicine)