The next phase of reform will see major trauma go to regional centres, leaving smaller A&E units facing an uncertain future. Will they become unviable? Alison Moore finds out

The regional 10-year plans produced as part of Lord Darzi's next stage review envisage major trauma typically being concentrated at just one or two centres per region.

Stroke and primary angioplasty services will be on more sites than trauma, but not at every accident and emergency unit. Emergency surgery, consultant-led maternity and inpatient children's services are also likely to be concentrated at fewer units.

This is likely to mean that some smaller A&E units lose patients. Since these units are often the backbone of local hospitals and cherished by their communities, what will be the consequences of this change?

The number of patients with major trauma, stroke requiring thrombolysis and primary angioplasty is small - less than 5 per cent of patients, according to Don Mackechnie, vice president of the College of Emergency Medicine. But the effects of centralising those services could have a major impact on what's left behind.

Inpatient children's services, for example, are likely to be provided at fewer hospitals in future. But this could mean an assumption that many children travelling to A&E towards the end of the day need to go to a hospital that provides overnight care.

The gradual centralisation of other services could also reduce the provision of "full" A&E services at some units. Retaining a consultant-led maternity unit is often crucial to keeping A&E services as maternity requires a round-the-clock anaesthetist - who can also cover emergency surgery.

On the move

Some of these centralised models will leave A&Es providing predominately acute medical care. The Royal College of Physicians says acute medicine units should have "prompt access to senior competent surgical review of acutely ill patients". Colin Borland, associate emergency medical director at Hinchingbrooke Health Care trust, points to the high number of emergency surgical cases that initially start as medical cases and are difficult to identify in advance.

Telemedicine may help provide expert surgical opinion; but some patients are likely to be transferred, or consultants may need to travel to see them. Transferring patients ties up an ambulance and, in many cases, an anaesthetist as the patient may require intubation.

There are also implications for staff in many of these changes: top-flight specialist doctors may gravitate towards centres providing stroke, trauma and primary angioplasty.

Accreditation for training purposes is another matter: will the royal colleges be happy with training roles where the trainee will never see - let alone carry out - serious emergency surgery?

Some junior doctors who are used to the backup of large hospitals can find it difficult at a smaller one where there is simply not the range of specialists on hand. Complying with the European working time directive can be difficult and some smaller units may look at a more consultant-based service at nights.

Models of centralised specialist emergency services will be particularly difficult in some rural areas where patients could be left a significant distance from a specialist stroke or primary angioplasty centre. The balance must be struck between the better results achieved by these units and the time it takes to transfer patients there.

There's a public perception that losing any of these core services is a slippery slope that will eventually lead to the loss of all A&E services.

Dr Borland says the effects can be both financial and clinical - as a hospital loses services, costs never fall as fast as income, and losing some services (such as maternity) has knock-on effects elsewhere.

But there are examples where primary care trusts believe this can be avoided, or at least minimised. In West Sussex, two A&E units may lose emergency surgery, including the majority of trauma cases such as hip fractures, but the primary care trust expects the remaining emergency services to be viable as they stand. They will be supported by intensive care units and still provide emergency medical care.

Louth County Hospital in Lincolnshire stopped providing round-the-clock A&E consultant cover and emergency surgery some years ago. Now Lincolnshire PCT has consulted on proposals that would see GPs and nurses providing A&E services, with patients who need admission and care by a specialist being treated elsewhere. The PCT - which says the proposals reflect pressures around specialisation, working hours and implementing National Institute for Health and Clinical Excellence guidance - believes fewer than 10 of the 360 people treated there each week would have to be treated elsewhere.

But with overnight cover for medical beds being provided by GPs there may be some limitations on medical admissions.

NHS Confederation policy director Nigel Edwards suggests that the greater threat to A&E departments could in theory be at the opposite end of the scale - from losing custom to other options for more minor conditions. This could include urgent care centres, polyclinics, walk-in centres and GP or nurse-led minor injuries units; urban A&Es may be particularly affected.

Financially, this could be bad news for acute hospitals that currently get a useful stream of income from this. Although payments were reduced a couple of years ago, acute hospitals may be reluctant to give them up.

But will this diversion actually happen? Mr Edwards is sceptical, suggesting that creating new options for patients sometimes seems to create its own demand among patients who might otherwise self-treat or simply wait and see. Total patient numbers may actually increase and it is by no means certain that the anticipated shift from A&E will materialise. Financially, that would be bad news for PCTs that risk funding new facilities while still paying for A&E visits.

New roles

King's Fund policy director Anna Dixon argues some units will need to redefine their role - "developing rehabilitation stroke care or minor injuries units and walk-in services for people seeking urgent help and advice rather than remaining a destination for ambulances".

Protocols and training are both likely to be important as ambulance services will increasingly have to decide not just which is the nearest A&E unit but which is the best one for each patient.

Ms Dixon says: "This system does, of course, rely on ambulance services effectively triaging patients and identifying which specialist unit a patient requires."

Frontline staff will need to do this successfully so patients do not end up far from home unnecessarily or miss out on gold standard treatment. "We are very dependent on who sees them first and how competent they are," Dr Borland says.

Dr Borland, whose own hospital seemed likely to face cuts two years ago, now feels it has a viable future handling 35,000-40,000 A&E attendances a year. NHS East of England has unusually committed itself to supporting A&E departments in every trust and has even spoken of the need to meet the extra costs of smaller maternity and A&E units.

Don Mackechnie warns that a system set up to benefit people with major trauma, stroke and minor injuries cannot disenfranchise everyone else.

PCTs - and possibly government - may have to accept additional costs if A&E departments in these areas retain a wider range of services than their catchment area seems to justify.

"We have to get it right for everybody," Mr Mackechnie says. "It is no good saying that because someone lives in West Cumbria, they can't get an equitable service."

Delicate balancing act

NHS East of England has 17 trusts, some of which have A&E departments that have previously been under threat. It would be easy to assume the recent regional Darzi review could raise questions about their future.

"But the idea that we could manage with fewer A&E departments was not something that we considered for very long," says the strategic health authority's medical director Robert Winter. Chief executive Neil McKay has also publicly said they will stay.

Distance between units, a growing population and the fact that most existing centres already serve large populations ruled out much change. The challenge was to find a solution that would sustain all the units while providing gold standard treatment for patients who need specialist care.

There will be some concentration of major trauma work - which is only 0.1 per cent of A&E work - and four or five centres for primary angioplasty will be developed.

But care for patients presenting with stroke - of whom there are a significant number - is likely to be provided through a clinical network.

Units that want to take part (it looks as if all 17 will) will need access to round-the-clock scanning, although some results may be read remotely.

This should identify the patients who will benefit from thrombolysis, some of whom may need to be moved to another unit. The need for 24/7 scanning facilities is likely to be enforced through PCT commissioning.

The SHA is encouraging trusts to develop thrombolysis skills, although Dr Winter says in some cases the throughput of patients may be too low.

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