The case for change

Four years ago, my wife and I were staying with my mother over New Year. At 10pm on New Year’s Eve she had a call from an elderly neighbour, sounding confused and saying that she thought she had muddled her medicines and taken the wrong ones.

We went round and found her on the floor. She had had a stroke. A GP quickly arrived and an ambulance followed nearly as promptly. She was in hospital in little more than an hour.

The next day we phoned.

Had she been seen by a consultant? Had she been scanned? The answer was no. This was a woman with every conceivable medical insurance policy, but they helped her not at all. At the moment she really needed it, the NHS failed her.

A specialist stroke unit with a scanner available 24 hours a day could have ascertained quickly if clot-busting drugs would help. They might have enabled her to make a better recovery, stay in her own home, and live longer. Professor Roger Boyle’s estimate is that, if the UK could match the delivery of clot-busting drugs achieved in other countries, 1,000 stroke victims a year would void becoming dependent on others.

But what is needed is a unit staffed and ready to go 24 hours a day, seven days a week, even New Year’s Eve. No district general hospital can achieve that today. Most cannot even meet a basic target of a brain scan within 24 hours.

Most patients who attend A&E departments are not emergencies at all. They are people in pain, or uncertain that anything is wrong with them. A&E doctors handle them admirably, but are less able to deal with the acute medical emergency. For such people, specialist units could be life-savers.

Providing such units at every district general hospital is impractical, because the volume of work is too small. They would be in major cities or regional centres, each responsible for a population of a million or so.

Local hospitals would lose vital medical skills

The case against

Taking an A&E department away from a hospital sounds like minor surgery, with no real effects on the rest. But the effects are more profound.

The removal of an A&E means that the synergy of elective and emergency surgery is lost. When there are no admissions for medical emergencies or trauma, the skill of the surgical, medical and nursing teams suffers. Opponents say that the effect ripples across the hospital, endangering other services including intensive care.

As services are lost, the hospital can no longer provide sufficient opportunities for training young doctors, and may lose accreditation with the Royal Colleges. Staff become demoralised and the hospital declines.

For patients, the effect is obvious: they are likely to have to travel farther. It is hard to persuade them that an extra hour in an ambulance will be compensated for by better care at the end of the journey. Experience suggests that there may also be longer waits for patients with minor injuries who attend the A&E clinics that are left.

There are also concerns about how well ambulance services will be able to cope with greater distances, unless they are provided with more staff and greater resources.

If the loss of A&E units is balanced by the creation of specialised units, there is some compensatory benefit. But there have been no guarantees of funding for such units and, in the pressure to balance the NHS books, that half of the equation might be lost.

A final element that carries a lot of political weight is local pride. People prize their hospitals and feel their loss keenly. Clinical arguments, however well expressed, seldom deal with people’s emotional response to threatened closures.

That is why repeated recommendations for NHS reconfiguration, produced by health authorities often after lengthy consultation, have gone unheeded. Ministers have been nobbled easily and have chosen the easy way out.

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