Proposed A&E Guidance: Department of Health responds

The Department of Health has responded vigorously to reports and comments about the proposed guidance suggesting that full Accident and Emergency departments should have a catchment area of 450,000 to 500,000 residents.

A Department of Health spokesman said yesterday that the figures were "wrongly interpreted" by the NHS trusts in Surrey which had referred to them as "national guidance". He said that there was no such official guidance from his department.

However, he admitted that the recommendations were taken from a report by the Royal College of Surgeons supported by Sir George Alberti, the former director of emergency care. Sir George recently recommended the closure of an A&E department in north London. The remaining two A&Es serving the area will be left with catchment populations of 450,000 each.

The Department of Health has described the report as "guidance in a consultation document" and added that "The DH receives guidance from all manner of bodies and expert groups but this is not secret DH guidance and we are not forcing the NHS into 'closing' 92 A&Es."

The full text of the Deparment of Health response reads as follows:

"It is complete nonsense to suggest that half of all A&E's are marked for closure by the Department of Health. This is just wrong.

The Royal College of Surgeons of England reconfiguration working party issued guidance in a consultation document and this is the guidance to which the opposition refer in their document. The DH receives guidance from all manner of bodies and expert groups but this is not secret DH guidance and we are not forcing the NHS into 'closing' 92 A&Es.

Any decisions about the shape of A&E services are taken locally so that services reflect the needs of the local population. Where local health authorities believe that patients can be better served by changing the way services should be delivered, it is right that they make those changes, and they will consult locally on any proposals.

Patients across the country have seen the transformation of A&E services in the last ten-years, with record investment and innovative new ways of working resulting in an end to the long delays patients used to experience. Increasingly, emergency care is being delivered at different levels - through walk-in centres, minor injury units and specialist units to treat conditions such as stroke as well as in A&E departments.

In many areas hospitals are changing because medicine is changing. The most specialist care (eg primary angioplasty for a heart attack) needs specialist teams and can't be done in every local hospital. If we know that the NHS can improve and save more lives by changing services, we would be betraying patients if we refused to support change just because it's difficult.

Far from closing hospitals, we have already opened or are building over 100 new or refurbished hospitals - with more to come. We are investing another £750 million in new community hospitals. We have refurbished over 2800 GPs' premises and opened 106 new primary care centres."

I am of course pleased to learn that the Surrey NHS Trusts which referred to this document as "national guidance" had apparently misunderstood the status of its recommendations. However, I make no apology for raising the issue.

Indeed, now is the time to make a fuss - before the Royal College of Surgeon's working party recommendations do get adopted as national guidance. Because if these recommendations were adopted as guidance by the Deparment of Health, and were rigidly applied by Strategic Health Authorities and local NHS trusts, the consequences for Cumbria and many other parts of the UK would be every bit as dire as suggested in my previous post.

NHS Guidance of one A&E unit per 450,000 people would be a disaster for Cumbria

I am deeply alarmed at suggestions that at least some some health authorities have been advised that the catchment area for NHS Accident and Emergency Units should be between 450,000 and half a millon people.

If applied in Cumbria this would mean the closure or downgrading of at least one and possibly two of the three A&E units in the county. We currently have A&E facilities at the West Cumberland hospital in Whitehaven, Furness General hospital in Barrow, and Cumberland Infirmary at Carlisle, serving a population which is nowhere near enough for even two A&E units, never mind three, if this target were strictly applied. Given that part of South Cumbria obtains A&E services from Lancaster Infirmary, the population of the whole of the rest of Cumbria is about equivalent to the proposed catchment area for a single A&E unit.

Over the North West as a whole, there are currently 33 Accident and Emergency units for 6.8 million people. Of these no fewer than 18, which is well over half, would have to be closed or downgraded to bring the average catchment area up to 450,000 people.

Such a policy appears to be completely absurd, especially as there is no clinical advice or basis to justify the proposed range of 450,000 to 500,000 residents. Yet the Department of Health does seem to have ordered at least some Health authorities to design Accident and Emergency services so that each major A&E department serves a population of at least 450,000 people. The guidance has been referred to in strategy documents prepared by local NHS organisations in Surrey, and by the Department of Health’s director for emergency care.

A document prepared by the West Surrey NHS confirms that

“Current Department of Health and Strategic Health Authority guidance suggests that to be viable in terms of patient need, patient safety, staffing numbers and clinical training requirements, a full A&E department in the future would need to be supported by a catchment population of between 450,000 and 500,000 people.”

(West Surrey NHS, Clinical options workshops, March 2007; http://www.conservatives.com/pdf/AEcuts.pdf)


A staff briefing by the Surrey Primary Care Trust in March 2007 similarly confirms that:

“National guidance – full A&Es to serve a catchment population of 450,000-500,000 people.”

Source: Surrey Primary Care Trust, Creating an NHS fit for the future: staff briefing, March 2007; available at: http://www.transition.surreypct.nhs.uk/fit-for-the-future-briefings/Fit_for_the_Future_Staff_briefingsMarch_2007.ppt.

The figure of 450,000 appears to have been plucked out of thin air, and is not the figure recommended by those leading clinicians who do support the idea of a minimum recommended catchment population.

For example, the Royal College of Surgeons of England published in March 2006 the document
"Delivering High-quality Surgical Services for the Future", which recommended a minimum catchment population of 300,000.

Even the Royal College of Surgeons proposals could, if implemented in a more rigid way that I hope and think they are actually suggesting, have dire consequences for Cumbria. The latest DOH guidance as quoted in the Surrey documents would be far worse.

However, other leading doctors take a broader view of the needs of less densely populated areas and also suggest that the number of patients treated, not population, should be the main guide to the size required for a viable service.

The British Association for Emergency Medicine and The College for Emergency Medicine, for example, demand that:

"Hospitals with attendances at A&E in excess of 40,000 per year should have, “immediate access to the key supporting specialties to allow an emergency department to function safely. The following should be available on site: intensive care, anaesthetics, acute medicine, general surgery, orthopaedic trauma. There should be rapid easy access to child health (preferable on-site), 24-hour access to imaging (including CT scanning) and laboratory services available on-site”.

Even those hospitals with fewer than 40,000 attendances at A&E per year should continue to retain A&E services, provided that, “they are able to demonstrate their effectiveness, safety and quality”.

Source: British Association for Emergency Medicine and The College for Emergency Medicine, Way Ahead 2005, 2005; available at: http://www.emergencymed.org.uk/temp/1337-pubs_way_ahead_2005.pdf.

Cumbrians should demand an assurance from our local Strategic Health Authority and PCT that the target of 450,000 to 500,000 people per A&E unit referred to in the Surrey documents will not be applied in the North West. If no such assurance is forthcoming, we have a real problem.

Doctors appointment website suspended

I am relieved that the controversial computor system for junior doctors to apply online for training posts as been suspended for the second phase of the process.

The system for appointing doctors to training posts has been going wrong in a big way for some time: at last, far too late, the government has realised they cannot just pretend it is working. Let's hope the issue is addressed with the urgency it deserves.

This matters to hospitals like the West Cumberland. Recruiting and retaining the best up-and-coming medical staff is vital to our fight to keep a good range of top-class services. We cannot afford the kind of train-wreck which has been developing with doctor training and appointments.

Hospital Petition passes 400 signatures

To date we have collected well over 400 signatures on our petition to support local hospital servies in Cumbria and against CATS in it's present form or any other form which might damage existing hospitals.

We are still collecting signatures and anyone who would like to sign is encouraged to use a comment or email to contact me