The latest casualty of health reform: casualty itself

Published in The Guardian 04 April 2013

A&E departments are the pressure valve of the health system, yet the government is moving rapidly to turn it off

Accident and emergency departments are serially failing to meet targets, according to official figures released this week – which only confirmed what those aware of the growing pressures on hospitals already know.

Department of Health data revealing a repeated failure to deal with 95% of A&E patients within the recommended four-hour timeframe emerged shortly after the East of England ambulance service took the unprecedented step of erecting a “major incident tent” in which to treat patients outside the Norfolk and Norwich University hospital, in order to relieve pressure on its A&E unit over the Easter weekend. David Cameron’s recent attack on migrants’ use of NHS services diverts attention from the real story of what is happening to our accident and emergency services.

The Health and Social Care Act 2012, which provides a legal basis for charging and providing fewer services – in effect abolishing the NHS – has in fact removed the word “accident” from “accident and emergency services”. The significance of referring only to emergency care is now becoming apparent.

In January my local hospital, along with many others, erected large “STOP” signs in the entrance hall. “STOP – do you really need A and E? If your condition is not a serious, life-threatening emergency you may be directed to more appropriate health services.” A&E is being redefined as only for life-threatening conditions, when for more than 60 years it has provided urgent care and attention to all – whether it be a child with a rash and a high temperature, a road traffic injury or an adult with a heart attack. Patients are not physicians: everyone who goes to accident and emergency has an unmet need for a medical opinion.

The accident and emergency department is the pressure valve, the last point of entry to funded care when all other routes are closed, the canary in the mineshaft: when A&E admissions rise, it is a signal that there are problems in all the other parts of the system. And A&E attendances are continuing to rise now. Hospitals have started to advise us that if our emergency is “not life-threatening”, our first choice should be to go to a local pharmacist. Pharmacists are, for the most part, employed in private, for-profit pharmacies, all with commercial conflicts of interest, namely to sell medicines and treatments that we do not need.

And what of the alternatives? Out-of-hours services, including NHS111, are difficult to access, increasingly privatised and not trusted by patients. GPs no longer have an open-ended 24-hour duty of care. Services once integral to family medicine are being broken up and privatised.

Now the government is moving to turn off this pressure valve at breakneck speed, and its proposals could close more than 24 NHS hospitals and A&E departments across the country.

All these hospital service closures are being triggered by commercialisation and efficiency savings. A multibillion-pound debt mountain has been created by the obligations of the private finance initiative, which is gobbling up hospitals’ income and leaving less and less behind to pay for nurses and care.

Government claims that closures are necessary for centralisation and quality of care are poppycock. Although the national health service returned a surplus of in excess of £3bn to the Treasury over the past two years, healthcare trust deficits are behind the mergers that are driving A&E closures. The only beneficiaries of hospital closures are doctors in private practice, the corporate chains operating private health insurance and, waiting in the wings, private hospitals.

The new bodies unleashed by the Health and Social Care Act – clinical commissioning groups (CCGs) – are offering GPs enormous financial inducements to reduce the number of visits made to emergency departments and admissions (bizarre when they have no control over out-of-hours care). American health industry software can be used to identify those repeat offenders among us who are at high risk of A&E attendance. The same software can be used to penalise GPs whose patients are persistent attenders at A&E. The NHS confederation has proposed extending NHS user charges for hospital and GP visits, or capping the number of visits, quite ignoring decades of research evidence about the catastrophic effect that this would have on access and the poor.

Taking another leaf from the US industry’s book, the new act gives providers and CCGs extraordinary freedom to decide which patients they will take, what services will be provided, and who will be treated free. Today patients in England must show proof of residency to join a GP’s practice; tomorrow it is likely that proof of CCG membership will be required to be given access to any service, including emergency treatment and care. Entitlement will no longer be something we can all take for granted.

The deletion of “accident” from accident and emergency services; the softening up of the public to accept that emergency services are only for life-threatening conditions; the forced closures of A&E departments and the complete break-up of GP services – all this follows from the act that is dissolving the NHS.

Our only hope lies in slowing down the rate of commercialisation and service closures. A political campaign to reinstate the NHS has begun. Earlier this year David Owen laid the National Health Service (amended duties and powers) bill in the House of Lords. Its purpose is to restore the duty of the secretary of state to provide and secure comprehensive healthcare throughout England – a duty that has been in force since 1948.