Why A&E departments are fighting for their life
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Version 0 of 1. Not a week passes without a news story about A&E departments: seven threatened with closure in London; ambulances queueing around the block as patients wait for hours to be seen; insufficient staff; high spending on locums. Emergency medicine is a tiny speciality, with fewer than 4,000 doctors in contrast to 32,000 GPs – and yet it consumes an inordinate amount of airtime. Why? A&E is the canary in the mine; it tells the story of what is going on elsewhere in the service. Cuts, competition and the fight for survival are at the heart of the story. Over the past 20 years many hospitals and A&E departments have been closed, usually as part of private finance initiative projects: what drove the closures was the high price of PFI, not changing patient needs. Hospital beds have been lost at a rapid pace too, not because there isn't a need for them, but because the government is paving the way to divert patients to the private sector in the future, or removing NHS services to allow foundation trusts to generate income from private patients. Over two and half decades successive governments have closed over 50% of NHS beds. In 2013/14 there were 135,000 NHS beds compared with 297,000 in 1987/88. England now has one of the lowest number of beds in Europe and the highest bed occupancy – over 100% in some specialities – which means medical patients are being displaced on to surgical wards, leading to cancelled elective surgery and increased waiting times. And without beds, pressure builds in A&E. No one is monitoring or measuring this: community health councils, once the voice of local people, have long since been abolished, and there is no census of emergency departments. At the same time, the government is closing services in primary care and local authorities are axing services in social care. GP out-of-hours services are no longer functioning as they should and neither are social services and community support. More pressure builds. The Labour government set up walk-in centres and minor injury units as an alternative to GP out-of-hours services. But now these are also being closed; of the 230 opened under Labour, 53 have shut down in the past three years. Contrary to popular belief, attendances have stayed static since 2003 in what the Department of Health calls type 1 units – the big hospital-based A&E departments. The increase has occurred in type 2 and 3 units – the minor injury and walk-in centres – and so can be explained by the decline in GP out-of-hours services. So why are alarm bells sounding in the big A&E departments? Since the Health and Social Care Act removed the duty on the secretary of state to provide universal care, it is every hospital for itself, competing against each other in a market place; there is no planning, only forecasting for income and sales. But A&E is expensive and, like geriatric care and children's services, the price the government pays may not meet the costs. Hospitals would rather concentrate on niche markets like cancer, cardiac and elective care, especially if they can raise some private income at the same time. Markets don't like risk or uncertainty. Thus the new NHS pricing model works against A&E. Professor Keith Willett, the man leading NHS England's review of emergency services, has described the model as "wrong", and says it has led to an "adversarial" relationship between hospitals. But it is not just between hospitals – it is also within each hospital, as speciality fights speciality for survival. This means specialisms lobbying for resources, and trying to raise their voices above all the others in order to be heard. At the moment A&E is shouting the loudest. Our editors' picks for the day's top news and commentary delivered to your inbox each morning. |