An analysis of documents drawn up to remodel the health service in England shows that 24 casualty units from Durham to Somerset have been marked for potential closure despite record demand for A&Es and serious overcrowding across the country as the NHS goes through its most severe winter crisis since records began. Last month produced the worst performance for A&E waits in 13 years.
NHS bosses who have drawn up the changes as part of efforts to plug a £22bn hole in the health service budget by 2021, insist that concentration of specialist urgent services could save lives and there are no plans for a “significant” reduction in the existing number of 175 emergency units.
But one senior emergency doctor told this newspaper that the plans amount to proposal to “make the River Nile run backwards” by planning for a reduction in demand for A&E services at a time when Britain has a growing and ageing population.
Research based on 44 regional blueprints by the Johnston Press Investigation Unit reveals that managers are planning to cater for up to 30 per cent fewer A&E visits and plans have already been advanced to downgrade units to urgent care centres (UCC) with fewer specialist or consultant-grade staff.
In north east London, the King George Hospital will see its A&E become a UCC by 2019. Similar plans are under consideration in Dewsbury, West Yorkshire, and Poole in Dorset. In Staffordshire, health bosses have set a goal of a 30 per cent reduction in A&E visits; in Norfolk the figure is 20 per cent.
A separate study by the Health Service Journal (HSJ) has found that around 15 per cent of the total number of A&Es face closure or downgrading with several areas facing “either/or” decisions between neighbouring units.
Under the five-year project to plug the hole in the NHS budget in England, Sustainability and Transformation Plans (STPs) have been drawn up for each of 44 “regions” to remodel services.
A key part of the scheme is to reduce reliance on hospitals, in particular A&E units, by expanding primary care into integrated “hubs” staffed by GPs and other carers, bolstered by technology and teams to carry out home visits.
But emergency medicine experts argue that the NHS lacks the additional beds and community care resources that would be required to cope with such a change. At a time when 12-hour trolley waits have doubled in the last two years, they accuse managers of basing the future of the health service on “wishful thinking and rhetoric”. According to leaked figures, some 780 people last month waited more than 12 hours for a bed while in A&E - compared to 158 in January 2015.
Dr Chris Moulton, vice president of the Royal College of Emergency Medicine (RCEM), said: “A&E units are already desperately short of capacity and hospitals have almost 100 per cent bed occupancy. The suggestion that you can close A&E departments and then somehow fewer people will become ill is clearly ridiculous. And anyway, it is not people with minor illnesses but elderly patients with serious conditions who are the ones lying on A&E trolleys waiting for beds and then languishing on the wards awaiting social care.
“The problem is that the STPs are trying to design the health service around the fallacy that you can downgrade A&E departments and then not provide comparable capacity elsewhere. They are predicting a pattern of falling demand when A&E attendances have consistently risen for decades. There is no clear indication as to how this miracle might be achieved.”
He added: “We have a rapidly growing and ageing population and therefore the idea that the health service won’t have to deal with even higher numbers of people requiring emergency care and hospital admission in the future is like hoping that the River Nile will run backwards.”
The professional body said that while it agreed that numerous units were facing change, it was only aware of five A&Es at immediate risk. But it warned that a decision to implement 24 closures - equivalent to one in six of the total - was unthinkable.
The HSJ, which said it was aware seven closures or downgrades already in the pipeline, found that 26 hospitals were involved in “head to head” comparisons which could result in one unit being maintained or upgraded to offer full emergency services while the other nearby A&E could be closed or offer reduced care. Such decisions are being considered in Shrewsbury and Telford; and Bedford and Milton Keynes.
Some clinicians argue that such moves to concentrate staff in two overstretched A&Es into a single unit can be a sensible use of resources and will not necessarily result in a loss of capacity.
But campaigners and experts warn that widespread closures will result in longer journeys to the nearest emergency units and place an unsustainable burden on remaining services.
Dr Taj Hassan, RCEM president, said that while the STPs had “admirable” ambitions they were in their present form “unworkable”.
He said: “If it were to come to pass that one in six emergency departments are downgraded, the effects would be disastrous.
“Closure of any emergency department will naturally require more beds to be found elsewhere - patients do not just disappear when an option for care is removed.”
The National Health Action Party, which campaigns for improvements in health service funding and staffing, said the STPs offered a grim picture which could ultimately see the number of full A&Es whittled down 70.
A spokesman said: “According to the STPs, to make the NHS affordable and sustainable, we the public must get used to longer ambulance journeys for emergency care, longer waiting times for treatment. There is a shortage of doctors and nurses. Our A&Es no longer have a mid-winter crisis, they have a year-round crisis.”
At the heart of many STPs is a new strategy which will seek to divert many people from attending casualty by referring them to a range of alternative services from walk-in minor injury units (MIUs) to teams dedicated to treating people at home.
The North and Central London STP envisages an Acute Care At Home service under which patients, for an example an elderly person who has suffered a fall judged by paramedics not to require A&E treatment, will be referred electronically by ambulance staff to an alternative team who will visit within 12 hours.
Clinicians agree that such schemes are desirable but question whether they will save money or function effectively. In north Essex, managers are considering plans to two out of three minor injury units while in Worcestershire last month four MIUs were closed for three days so staff could be redeployed to support struggling A&Es in Worcester and Redditch.
An NHS England spokesman said: “The number of people seeking urgent care is on the rise so overall we expect the range of services available to them to expand over coming years.
“Within that overall expansion, it may be possible to improve care and save lives with some concentration of specialist urgent services. This approach has increased the chances of surviving a major trauma in this country by 50 per cent, and only today the Stroke Association have called for more concentration of stroke units to improve outcomes. However we do not expect significant numbers of A&E changes in the years ahead, and many schemes were in fact decided on many years ago so this is a rehash of old news.”