The health debate in this country is always a blend of politics (the battle between the parties), policy (the debate over how to improve services) and delivery (what actually happens on the ground). Of course, the latter both depends on – and shapes – the former but, in the era of NHS reform, it receives too little attention.
Many factors shape delivery – money, circumstance, and the ability of healthcare professionals and managers are all important. But, in this most evidence-based of sectors, it is public attitudes which often determine what delivery is possible. And nowhere is this more the case than with accident and emergency units.
I have blogged before about the saga of Chase Farm Hospital, which ultimately led to the announcement in September that it will lose its A&E. But in the last fortnight, we have witnessed two further closures – apparently temporary – of overnight services at Central Middlesex and Stafford Hospital. This is not an issue which will go away.
In determining how A&E services should be delivered, the Government, NHS managers and clinicians face two major challenges.
First, as a member of the public, my understanding of what an A&E does is remarkably deep, detailed – and informed almost entirely by watching Casualty, ER and Grey’s Anatomy (the latter two give me an important transatlantic perspective on the issue). Staff are hard-pressed, they are stressed and they are struggling to cope, sometimes because of their jobs and often because they are in and out of relationships with each other. A&Es are busy places, with busy people. They deal with bruised children, brain trauma, victims of savage violent assaults, outbreaks of infectious disease, train disasters, and plane crashes. I know all of this because I have seen it on television.
Second, as a member of the public, I do not want to see my local A&E cut in any way. This is not because of some attachment to local bricks and mortar. It is because I understand the personal health consequences of such a move. What would happen if I became a victim of a savage violent assault? What would happen if I had a serious brain injury? Or if my plane came down?
I can understand why the people around Chase Farm, Central Middlesex and Stafford are concerned.
So that is the starting point on which we can begin an informed discussion about what A&E services we actually need to deliver high quality urgent and emergency care. Yet this public perception is not entirely consistent with the reality of many A&Es.
A&Es are not in general consistently and remarkably busy places. On the NHS press release announcing the closure of Central Middlesex, it is explained that the A&E there sees one or two patients a night. And these patients are not necessarily blue-light patients. That is a lot of resource to keep the service open for apparently little health need.
Now that may be unique. But I suspect it is not. According to the national figures, just under 15.6 million attendances at A&E were reported by providers in the last year for which complete data are available (2009/10). That aggregated figure seems very high. But there are many sites reporting data. The median daily attendance rate was only 230 patients a day. 36 providers reported helping less than 150 patients a day. Consider, too, that attendances peak during Friday and Saturday nights – meaning that attendances might drop to, say, 70 a day in the smaller A&Es during the rest of the week. And then consider that the vast majority of these attendances will be during the day (82% of attendees arrive between 8am and 9pm inclusive). That means that, at night time, a large number of the smaller A&Es must be seeing around one or two patients an hour. And, I would not be surprised if there are a few more Central Mids out there, seeing even one patient a night. The latest figures for April – June 2011 show a similar picture (total annualised attendances appear to be up, the median daily attendance appears to be lower).
These figures not only challenges my worldview (developed in association with Casualty), but also undermine my confidence in the importance of having an A&E on my doorstep. Just as I would rather have my car fixed by a mechanic who saw five cars a day instead of one, I would rather have my brain fixed by someone who has done something similar in their recent memory. This also indicates that money may not be enough to enable my A&E to deliver the service I want. What would be the point of employing more mechanics at my local garage to ensure that it is available 24/7 if they are still only seeing one car? I still wouldn’t want to go there.
Of course, in the real world, I imagine I’d end up anywhere but my local A&E. With specialist services available, if I had severe brain trauma I’d be taken somewhere (I hope) which has some people who know what they’re doing and get plenty of practice at it. And if I had any capability at all and wasn’t being taken there, I’d be having this argument, in the ambulance. For the most serious conditions, the last place you’d want to end up – and the last place most people do – is the local district general.
Specialisation has delivered better care – in conditions such as cancer, stroke and trauma it is thankfully the norm. But as we’ve ended up with fewer, larger centres doing the heavy-lifting, we’ve tended to leave something behind. The A&E sign.
I doubt that many hospitals with an A&E sign do actually now have a Casualty-style A&E. But explaining that to people is politically toxic. At Newark Hospital, a decision was made this year to take down the A&E sign. Why? Because the hospital has never had an A&E an the sense the public understand it, but this didn’t stop a ‘save the A&E’ petition being launched when the sign-change was first mooted.
We have written before on this blog about the political impact that changes to hospital services could have. In truth, many of these changes will not be full-blown closures, but will instead focus on the downgrading of some services – notably A&Es. There won’t be a strong clinical case for all reconfigurations, but for many there will. And there is a strong clinical case for stopping A&Es which fundamentally are not A&Es from taking patients out of ambulances and trying to treat them. Yet this will still be a political nightmare.
As a member of the public informed by Casualty, and thus a probable signatory to the hypothetical petition to save my local A&E, what advice might I give the Government on what they can do to help manage this nightmare?
As a start, I would argue that campaigning against changes in opposition can create hostages to fortune in power, but that particular ship has sailed. Beyond this (and more within the realms of political likelihood) I would like to see more information published which might enable me to understand the true nature of my local A&E.
Publishing A&E clinical quality indicators – as the Government has done – is a good start, since they help to expose the scale of variation in the quality delivered by each A&E. But I, for one, would like to know more. I would like to know which services are delivered at which A&Es; I want to know if someone does have a stroke on my road, where would they be taken? I would like to know how many patients are actually seen at each A&E, day and night. All of this information is already collected – ambulances know where to take which patients, and the 4-hour waiting time target captures each patient to come through the door – so it should not be beyond the wit of policymakers to make that happen.
So basically, my bargain is this: I want the Government to do two things and then I’ll do something in return.
First, I want them to tell me what an A&E actually is. And then I want them to tell me if my local A&E is actually an A&E.
And then, for my part of the bargain, I won’t sign the petition calling for services which don’t exist to be saved.