Health hotel: the road less travelled

One of the most controversial health topics of the 2007 party conference season will be reconfiguration of hospital services in England and whether patients will be travelling too far for treatment.

Since last year, there has been talk of a radical reconfiguration - the Royal College of Surgeons said the number of fully equipped accident and emergency departments could be slashed from 200 to 100 under the right kind of reorganisation.

NHS chief executive David Nicholson has said each of England's strategic health authorities should consult on about half a dozen reconfigurations over the next year, while think tank the Institute for Public Policy Research has published a paper saying there are about 58 'excess' hospitals which should be merged with peers.

The debate was reignited by research in the September Emergency Medicine Journal, which said longer ambulance journeys raised the risk of death for seriously ill patients. The researchers studied 10,315 patients taken to hospital by four ambulance services over a five-year period. Patients were either unconscious, not breathing or had chest pain.

The further seriously ill patients had to travel to receive emergency care, the researchers concluded, the more likely they were to die. People with respiratory problems were at greatest risk.

Animated debate

This contentious subject will be discussed at a key fringe event taking place at all three main party conferences as part of the Health Hotel. Entitled 'What's a safe distance to travel to hospital?', the event will feature presentations from the Alzheimer's Society, the Health Foundation and the Royal College of Surgeons.

It promises to be an animated debate and to grab a great deal of attention, according to Health Foundation chief executive Stephen Thornton: 'This is a very serious, bubbling political healthcare policy issue, a big 'P' political issue of concern to the two main political parties and it's of interest to local people.'

The foundation does not have a view for or against a particular standpoint, but wants to provide a platform for the issue to be debated. 'One of the things we try to do at the Health Foundation is to encourage people to base their thinking, their policy and their views on some evidence,' says Mr Thornton.

'Any evidence that is brought to bear on this issue, whether it comes from a clinical source or a patient perspective, is important and valuable. We want an opportunity to bring a range of people together with different perspectives on this, just to get across a simple message that this is very complicated. There is no absolute straightforward right or wrong answer about exactly where these services should be located.

'We are bringing those parties together over what is quite deliberately a very controversial issue, which we know people will flock to, and we are providing a neutral platform to do that.'

The recent research, adds Mr Thornton, does not simplistically conclude that in all cases patients are more likely to die the longer it takes them to get to A&E.

'It picks out that there are certain conditions and certain circumstances where that appears to have been proven. That is a really useful and interesting contribution to the debate. We don't have any work in progress at the moment that is looking at this issue and we don't, therefore, have a view [that] it is right to have trauma centres or not right to have trauma centres.'

The idea of focusing services in specialist centres may be hard to swallow but it makes a lot of sense, according to Royal College of Surgeons council member Dermot O'Riordan. Mr O'Riordan, a consultant surgeon at West Suffolk Hospital trust, will also be speaking at the fringe events. 'The public [needs] to realise that there are decisions to take in all of medicine,' he says. 'You can't have an all-singing, all-dancing hospital everywhere.

'More important to the people who organise the health service is why a person is having to travel. We support the concept of people travelling if they get better care when they arrive.

'If you have a common condition that is not particularly specialist or rare, then travelling won't necessarily help you. But there are some conditions where you will get a better outcome if you travel.'

There are a number of reasons why reconfigurations of hospitals are on the horizon, he believes. For example, some patients will get better outcomes for their conditions if they travel to a specialist trauma centre.

But he admits there are other reasons: 'For instance, a number of hospitals have difficulty in staffing both acute and on-call rotas because of the European working-time directives. That may be why some places are rationalising their services. The directives are making life difficult for some hospitals to continue to provide care on all the hospital sites where they currently do so.

Patient's perspective

'It is a difficult message to sell to patients and it becomes a matter of involving the public and helping them to understand the issues. If such a decision is taken purely on financial grounds, then that's not something we'd support, but if it's done for the quality of care when you get there, then we support that.'

Many patients are worried about the implications of closing some A&E departments - a view that will be voiced at the fringe event when a representative patient with dementia will speak on behalf of the Alzheimer's Society.

Alzheimer's Society senior campaigns officer Vicki Combe says: 'We want to bring a patient's perspective to the issue because people with dementia are patients like anyone else. We are in contact with lots of people with dementia and they are worried about having to travel further, for example, for A&E services.

'We wouldn't say there's never a case for moving A&E services further away, but the public need to be involved in the debate and understand the issues. There is a lot of focus and concern.

'Quality of care is important to people as well and there are trade-offs, but transport is important.

'One issue that comes up more and more is help with transport costs. If people have to travel much further then that will have cost implications and they may need help to cover those. There also needs to be really good public transport links to hospitals.'

Beyond the conference event, key professional organisations say they are yet to be wholly convinced by the EMJ study. The British Association for Emergency Medicine believes it should be taken seriously, but there is a bigger picture.

Association president Martin Shalley says: 'If we are looking at reorganisation of health services, we need to look at this [EMJ] paper and take it into serious consideration, but I don't think it's the be-all and end-all. It's part of the story and an interesting analysis that hasn't been done before. Looking at the whole patient journey is a much bigger piece of work.'

Mr Shalley, also a consultant in emergency medicine at Heart of England foundation trust in Birmingham, has mixed views on the proposals to close local emergency care departments in favour of fewer, more specialised centres.

'There just aren't enough doctors in some specialties to provide, for example, cardiology. Not every hospital will be able to provide all services, so it makes sense that specialist services are concentrated to deal effectively with those patients to give them the fastest possible intervention.

'But when you look at the number of medical emergencies per hospital, and if you close one hospital, that will have a huge effect on staffing and bed numbers at other hospitals.'

Mr Shalley says there are ways to improve care, such as giving all patients with chronic lung disease a card to carry that lets healthcare professionals know what percentage of oxygen is best for them.

'That happens in some places already. That would be a significant help to paramedics and emergency departments where it's not known what would be best for the patient.'

Paramedic role

What of the role of ambulance staff? Mr O'Riordan is among those who believe that however well trained ambulance staff are, there is a limit to the difference that they can make to outcomes. Others believe that ambulance staff's role is fundamental in this debate.

Mr Shalley says: 'It's the paramedics generally who, in conjunction with ambulance control, decide where patients go. The phrase "going to the nearest hospital" should be changed to "going to the nearest appropriate hospital for that patient".

'Huge efforts are being made to improve what ambulance staff can do. Many more crews do electrocardiograms and diagnose myocardial infarction, and in many isolated locations will do thrombolysis in the ambulance, which is tremendous. In some remote places where travelling to a hospital may be many miles, initiatives like these are tremendously important.'

He envisages a future where there are many more emergency care practitioners. These are either paramedics or nurses who are specifically trained to have greater skills in making clinical decisions, treating people in their own homes and arranging for patients to be seen in areas other than A&E, such as GP surgeries.

The role of air ambulances will also develop, he adds, saying: 'As there is development of specialist centres, there will be a much greater use of air ambulances to get patients to the right centre quickest.'

Sam Oestreicher, Unison national officer for health and secretary to the Unison national ambulance sector committee, believes the EMJ research suggests there will be a growing reliance on ambulance staff as services become more concentrated in specialist centres.

'The study was conducted in 1997-2001,' he says. 'Since then, as far as the ambulance service is concerned, it has been upgrading and looking at improving levels of care.

'The EMJ study raised a lot of concerns, but there needs to be a more up-to-date study and ongoing collection of data.'

Mr Oestreicher says the government's planned expansion of the ambulance workforce is welcome but he is less sure the resources to achieve that are in place. The plan for England is to increase the number of paramedics from the current 7,500 to more than 10,100 by 2011 and to increase numbers of emergency care practitioners from the current 660 to about 1,800.

'We need a higher-skilled workforce to deal with the huge increase in demand,' he adds. 'Demand has been rising by about 8 per cent each year for at least the past 10 years - that's 250,000 additional responses every year. If there are going to be more specialised centres and fewer A&E departments, ambulance staff are going to be the key to making that work because we will need more of them with higher skills to treat people on the longer journeys.

'Paramedics will need more training and that is why we will see more emergency care practitioners coming in.'

The debate promises to be lively.