Since 1997, the UK has seen an increase in healthcare spending on an unprecedented scale. Major changes to the structure of the NHS have taken place, together with strong target setting and ‘performance management’. These changes have been controversial, but have undoubtedly improved the quality of clinical services.
Despite this success, the public perception remains that Labour has somehow ‘let us down’ with regards to healthcare. The accusations of financial mismanagement in the NHS have been rebutted with difficulty, and it has been a challenge to persuade the country of the virtues of imposing financial discipline in the NHS. The latest set of reforms concern changes to the provision of emergency service care. Despite being necessary to enhance quality of care for the sickest patients, ‘reconfiguration’ may be one of the most difficult reforms to sell yet.
Both medicine and the technology it relies upon are changing fast. Clinical specialists are becoming sub-specialists with expertise in treating the most complicated diseases and injuries for which there were few remedies just a few years ago. For example, interventional cardiologists can now treat heart attacks by deploying stents (metal cages) into the coronary arteries to unblock them. This has revolutionised emergency cardiac care. To gain sufficient expertise, doctors need to treat these patients on a daily basis – rather than encountering them occasionally. These specialist doctors can only deliver the highest quality of expert care if they cover a large population of patients.
It is clear that regional trauma centres with immediate access to specialist surgeons provide the best results for the most critically injured. This can be seen by analysing the experience of patients in the USA and South Africa. Opponents of these reforms argue that patients will need to travel further and that this is inherently more dangerous than having several local less specialised emergency centres. This is not the case. At present, if a patient has a head injury they will be taken to their local district general hospital for diagnosis and then transferred to a neurosurgical centre for urgent treatment. If trauma patients were taken straight to a trauma centre where all emergency surgical specialties were available this would decrease the time from injury to surgery.
Implementing regional specialist emergency centres, dubbed ‘Super A & Es’, would inevitably mean a downgrading of some A & E departments within the region. Politicians in locations where an A & E department is threatened with proposed downgrading are incensed at these measures. There is a belief that the move is simply a cost-cutting exercise. The reality is that it is a medical necessity, and will improve the treatment of the most seriously ill patients.
So how should we determine which A & E departments are to be downgraded and which are to become ‘Super A & Es’? That decision should not be left to Strategic Health Authorities or Primary Care Trusts who have budgets to balance. There needs to be a national plan for emergency services which takes account of the size of regions and their populations. Each region should have a trauma centre with all surgical specialists available 24 hours a day and a helicopter ambulance service. Each region should also have a network of A & E departments, which can still deal with the majority of emergency care but without all specialists available 24 hours a day. In addition, for the majority of patients with less serious ailments and injuries, there should be local ‘Urgent Care’ departments, minor injury units, walk-in centres and improved access to GPs.
Closure of any local hospital service is inevitably going to be a political minefield. The government needs to clearly articulate that these proposals coupled with greater community treatment of chronic conditions are about improving care rather than cutting costs. Labour risks losing its NHS trump card at the next general election unless it skilfully negotiates the changes that are necessary on the rocky road ahead.