At the heart of concerns about reconfiguration and the future of our District General Hospitals is the issue around A&E Closures.


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

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  1. Karl Wallace says:

    This reconfiguration of of all services is about the lack of financial resources the decision is now being made by the commissioning body who dicated what services they want! Example to provide or not to provided acute NHs services. But the reason why I think local services should remain local is because of varibles such as demographics and of course geography which are unique to each indivdual area.

  2. Im not impressed with Irwin Brown’s essay. 1. He places costs uppermost in the debate. 2. It has been acceptable for 50 years to call small hospitals in smaller towns A&E, and that was a euphemism we all understood. Of course they didnt have the facilities of larger cities- and complex injuries or strokes etc,, or other conditions were automatically sent to other regional centres- everybody understood this !
    This is quite different to (A) A deliberate Policy of Closure of as many Public Hospitals as possible and the re-opening and re-jiggiong of those premises into Newer- Local Care Centres where they treat Public and Private Patients, where the aim of the closure is really the leveraging of Cash for PFI re-builds into posh centres for selling health Services to those with money. Effectively creating a two- tier health service, which means a rubbish,very basic, low cost NHS one, and real service from a Paying Health Service . That’s what is intended by the New labour market reforms of the last 13 years, and the Commissioning Boards are there to ration resources to the NHS very tightly and stop choke the effective running of a NHS- which will have the effects of forcing, and really to promote “BSBV market reforms” to press the development of privatised services onwards at all speed. and the Tories are open about that. We have to deal with all these questions in the Totality of whats happening and why. All the closures and all the cost cutting are designed to bring the reality of Market Forces into play in Health Services. Many technician grades, and other vital people in the chain are correctly very worried about redundancy, sackings, and takeovers, hiving off etc etc- as the whole system is now under threat ! New labour are not doing anything to stop or halt this ongoing process. Labour Parliamentarians don’t care tuppence on the whole, and Labour Councillors wave through all the reforms on the nod- as they think its their party policy anyhow.

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