Feature

Casualties of limited evidence?

Recent proposals that many A&E departments should close ignore the realities of inner-city health care, says Nikki Joule

The Audit Commission has recently published a report recommending further closure (and merger) of at least 30 accident and emergency departments. Its premise is that concentrating services in fewer, larger departments offers the potential for ‘short-term operational advantages and improved standards of care’. This may well be the case in theory, but in practice there are at least three reasons why many people would feel safer with a larger number departments even if some of those were smaller facilities.

First at least 20 of the A&E departments on the Audit Commission’s hit list are in London and the South East, but there is already unceasing and frequently unmanageable pressure on London’s A&E departments and, along with the rest of the country, A&E attendances are rising all the time.

At the end of 1995, the Greater London Association of Community Health Councils launched a report on the state of London’s health services based on a snapshot survey of London CHCs carried out last summer. It found that London’s health services were at crisis point and that A&E services (along with mental health services) were a key indicator of that crisis. Seven A&E departments have closed in the capital since 1992. A further four are earmarked for definite closure, two are under threat of closure and five have been reprieved having been previously threatened with closure.

An on-going picture of the state of A&E in London is being developed through the ‘casualty watch’ project. CHCs in London and elsewhere have been carrying out a regular casualty watch in their local A&E department for two years now. Nearly all the London CHCs participate in this brief, but effective, exercise whereby a snapshot survey of A&E departments is carried out simultaneously every month. Information is collected about those waiting on a trolley for treatment or a bed. The latest figures show waits of 23 and 21 hours in one central London hospital. When this information is collated across London (and other cities), along with information about notified closures to the London Ambulance Service, it reveals some of the catastrophic knock-on effects of temporary A&E closures and bed losses.

This crisis situation is not only found in inner-city A&E departments — many outer London CHCs report similar problems. The chair of Bromley CHC recently wrote to all its local MPs saying that pressures on the local A&E were ‘increasing alarmingly’. The March newsletter of Croydon CHC reports that it is seeking a full report on the ‘crisis’ experienced for the fourth winter running at Mayday hospital, where patients are having to wait on trolleys or even having to stay in ambulances because of pressure on beds. Apart from the discomfort to those delayed in ambulances this also prevents the ambulances from getting back on the road.

This leads to the second point: that people need speedy access to an A&E department. The Ambulance Service Association (ASA) has pointed out that the Audit Commission report appears to have ignored the impact of its proposals on ambulance services. The London Ambulance Service is already under increasing pressure. The last quarter of 1995 was its busiest ever by some ‘considerable margin’. The LAS is only just recovering from a series of major, well-publicised, disasters. It is not at all clear how it would cope with a reduction in A&E capacity in London.

Of course, not everyone accesses A&E departments by ambulance. But many people in inner cities do not have access to a car and require some form of emergency service within walking distance or, at least, via a direct public transport route. Travelling even short distances in London can be extremely difficult for elderly people, those with disabilities and those with children.

The third reason why Londoners, in particular, would prefer a larger number of local A&E departments is the safety net they provide for minor injuries and illnesses. The appalling state of primary care in London has been well documented and we are still a long way from having a tried and tested system of minor injury provision through either GP practices or dedicated minor injury units. In fact, the recent GLACHC report on London found that MIUs still had to prove themselves in London, particularly where they were replacing 24-hour A&E departments.

Arguments have raged for years about whether people should be using A&E departments for primary care, but the bottom line is that they do when there is no assured alternative. This is still the case in London despite promised improvements in primary care. In response to this, recent initiatives have involved GPs employed in A&E departments to provide primary care. These have been quite favourably evaluated by users and practitioners, but what is to be their future in the brave new world of mega accident centres?

All these issues raise more questions about the basis of the Audit Commission’s recommendations. Where is the evidence that closing more A&E departments will improve the situation? Why not start planning from where people are at now and provide services at the point of demand? How about developing some practice-based evidence and evaluating services from the users’ point of view?