It’s welcome news that health officials are planning a national review of Accident & Emergency services in England. We need an honest debate on both quality of care and funding
There is no doubt that a major review of A&E and urgent care services is badly needed.
In many ways, A&E departments are victims of their own success. The public trusts them, and they provide access to medical care at any time, day and night, seven days a week. But complex issues about quality, safety and affordability sit behind what many see as the front door to their local hospital.
Often medical emergencies require high tech, highly specialised treatment. The review by Sir Bruce Keogh, medical director of the NHS Commissioning Board, needs to set out a clear rationale for why and how the way we deliver emergency medicine needs to change. Its aspiration should be to create a climate for honest debate with healthcare providers, commissioners, the public and politicians, about how we achieve the best quality of care and treatment in a way that the NHS can afford.
These arguments need to be persuasive and reach out to the public, so that local protests do not result from every change in emergency services. It is understandable, and indeed heartening, that there is patient loyalty to local A&E departments. It is a measure of patients’ satisfaction with the service that they have received there.
The rationalisation of emergency stroke services in London has been held up as a model. Patients are now taken to a handful of specialised centres rather than their local hospital, and this has saved thousands of extra lives. But these reorganisations can cause knock-on problems for smaller organisations that stand to lose a portion of their activity.
After a stroke, patients are usually taken by ambulance to the new specialist centres and are not making the decision about where to go themselves. The situation for the ‘walking wounded’ is very different. The public often turns to A&E when another, non-emergency solution would offer safer, better care. This is one area where there is much scope for change.
Urgent care centres, designed to relieve the pressure on acute hospitals’ A&E departments have not proved to be the solution in their current form. This review must test whether it is the concept that is at fault or whether public education, information and persuasion has to be stepped up to make them effective.
We also need a fundamental review of how A&E services are funded, as it is clear that the current arrangements are simply not delivering the intended outcomes.
Trusts that exceed their 2008/09 activity levels are paid at just 30% of tariff. The remaining 70% is supposed to be used to improve preventative measures to prevent emergency admissions, keep people out of hospital A&E departments, and ensure swift timely discharge of patients who no longer need to occupy a hospital bed.
As winter pressures pile on and acute hospitals are forced to postpone routine activity, this can result in a double blow – trusts are paid just 30 % of the going rate for extra cases arriving in A&E, and they are not receiving their normal income from elective patients. And in the vast majority of cases, there is nothing that they can do about it.
Commissioners will have some difficult decisions to make about A&E services that are complex and challenging. It is essential that providers are at the heart of those discussions so that emergency services can be made more effective. The changes will inevitably impact on the whole of acute trusts’ services and these must be fully explored before any changes are made.
Chris Hopson is chief executive of the Foundation Trust Network
