Scandal of the A&E closures: Ambulance crews on brink of collapse as more and more patients need ferrying miles further
The controversial wave of A&E closures is bringing Britain’s ambulance services close to collapse, a Mail on Sunday investigation has found. At just one of the threatened units – in Ealing, West London – up to 50 patients every day will need an ambulance to take them to an alternative casualty unit if the department shuts down.
Ealing is one of 26 such units being closed or downgraded across England and Wales as part of a policy to centralise services – despite fury among patients and scepticism from medical experts.
The extra trips in Ealing – revealed in documents obtained under the Freedom of Information Act – could cost the London Ambulance Service around £6million a year, at a time when it is being asked to slash £53 million from its budget over the next three years.
The disclosure comes as a veteran ambulanceman reveals to The Mail on Sunday the desperate reality of A&E closures, while another paramedic claims ‘the wider public have no idea how bad things are’.
In other developments this week:
* The number of MoS readers putting their name to our petition to Health Secretary Jeremy Hunt has topped 15,000. We are urging him to freeze all shutdowns until they have been independently reviewed.
* Further internal documents demolished a key argument for closures – saying the few patients who would need the specialist care available in the centralised ‘super A&Es’ will arrive too late to benefit from it.
* Another emergency unit has been added to our list of axed facilities. The ward at Wycombe Hospital in Buckinghamshire is to close its doors for the last time tomorrow – forcing patients to travel 30 minutes to Stoke Mandeville.
* The East of England Ambulance Trust is preparing to cut the number of ambulances available overnight – despite A&E closures in the area.
Ealing is one of four A&E units set to close in North-West London, leaving it with just an ‘urgent care centre’ – a GP-led clinic which does not treat any urgent, life-threatening conditions. It already has such a centre, just a few yards from the fully-fledged casualty department, but once the A&E closes, that short journey down the corridor will become a road trip of between 20 and 45 minutes for those 50 patients a day who have more serious conditions than initially suspected.
Last night, one paramedic said: ‘50 patients a day – that’s an enormous extra load. In any 12-hour shift, you would be lucky if a crew could do more than seven or eight transfers of that kind, even if they didn’t stop, and worked each job back-to-back.’
He suggested that meeting this need would require at least three extra, fully staffed ambulances on the road at all times, at a cost of about £6 million a year. Moreover, additional patient transfers will be required from the other three North-West London hospitals which are set to lose their A&Es: Central Middlesex, Hammersmith, and Charing Cross. The estimated numbers for these have yet to be revealed.
A new report due to be published this week by consultant Tim Rideout, the former chief executive of the NHS in Leicester, states that the A&Es which will be left in North-West London will simply be unable to absorb the additional patients.
One of them, Northwick Park, is already so full that it is forced to shut its doors to new emergency cases one day in every ten. The patients turned away are currently usually sent to Charing Cross – one of the A&Es set to close.
Yet under the closure plans, set out over hundreds of pages of a so-called ‘business case’, no provision for the vast number of extra ambulance journeys has been made at all. Documents show that although the ambulance service has carried out ‘some modelling’, it has decided to do nothing until a decision on closures has been formally taken after the consultation period ends next week.
Only then will ‘further work will be completed on resources needed’.
The documents add that extra funding will be ‘forthcoming’. But at a public meeting in Shepherd’s Bush on Friday, no one could explain how the extra journeys would be funded or who would provide the cash.
An NHS spokesman last night admitted that no financial calculations had been made, but said that the number of patients would be less than 50 a day from Ealing. He added that patients who had to wait for an ambulance at the urgent care centres could be given pain relief. However, as we revealed in July, the centre will, in fact, be forbidden from giving anything but the mildest painkillers.
A London ambulance spokesman confirmed there were no detailed plans for dealing with the closures.
The position in other areas is similar. In Greater Manchester, the ambulance service said it has ‘no financial agreement’ to cover the closure of Trafford A&E, which treats 38,000 people a year. And in the East of England, paramedics said ‘dozens’ of ambulances face being cut despite several hospitals losing their A&E departments.
Three of the five night-time ambulances in Watford are likely to go, along with others in Hemel Hempstead, St Albans and Luton.
One paramedic from Hertfordshire said A&E closures meant ambulances were spending hours outside hospitals waiting to hand over patients. ‘It’s madness,’ he said. ‘The crews are stuck at the hospitals because the hospitals don’t have enough staff to cope because A&E wards are being closed down.
Both Hammersmith and Ealing hospitals in north-west London are st to lose their A&E departments
‘It’s frustrating because we know we could be helping more people but we can’t leave the patients at the hospital with no one to look after them.’
Another rapid response driver added: ‘We’ll be screaming for back-up but the ambulance will take two or three hours. Meanwhile, the patients’ condition is deteriorating and the family are getting angry. The cuts are having a devastating effect. The wider public has no idea how bad things are, and if the closures continue they will get much worse.’
The usual argument for the closures is to concentrate A&E in big hospitals that can provide specialist care for conditions such as stroke, head injuries and heart attacks. In fact, experts say this applies only to a small minority of patients: in at least 90 per cent of life-threatening cases, the critical factor is speed in getting treatment. Now The Mail on Sunday has obtained documents which show that, even for patients who could benefit from specialist centres, speed is just as important.
In Newark, Nottinghamshire, the closure of the A&E unit has caused the average time between 999 call and admission to a ward to soar from 90 minutes to over two hours.
The delay means paramedics have to administer blood-thinning drugs to heart patients – which prohibits the best treatment: the insertion of a ‘stent’ to open a coronary artery. Adrian Gilbert of the Association of Professional Ambulance Personnel said: ‘The closure of A&E departments means ambulances have to go further afield and patients’ treatment is delayed. In the end it is the patients who are suffering and reducing the number of ambulances is only making things worse.’
The Department of Health again refused to comment further on The Mail on Sunday’s campaign, other than to re-state previous policies that consultations on NHS change should ‘be robust and wide ranging with a focus on improving patient care’.
Don’t let A&E closures shut down our hospital, by Natascha McElhone
Hollywood actress Natascha McElhone has joined the fight to save a leading children’s hospital under threat from A&E cuts.
The respected children’s unit at Chelsea and Westminster Hospital in London is ‘at real risk’ of closure if health bosses push ahead with plans to centralise A&E services, according to hospital sources.
Chelsea and Westminster is part of the consultation to close four out of nine casualty units in North West London. Although other hospitals are more likely to be hit, there are fears that if the A&E is closed here, leading specialists will also leave, making it unsustainable.
Ms McElhone, whose late husband Martin Kelly was a surgeon at the hospital, described the threat as ‘a tragedy’.
The actress, who has starred in Ronin and The Truman Show, said: ‘This is one of the best hospitals in the country. I gave birth to my three sons there, and the hospital continues to provide an incredible service for my kids and all the kids in and around this area. It would be a tragedy if it was under threat.’
A petition to protect the hospital has attracted more than 6,000 signatures. Governor Wendie McWatters said: ‘If the consultation ruling goes against us, and our A&E services are downgraded, the knock-on effect for the hospital will be devastating. The Chelsea Children’s Hospital will be at real risk as its foundations are ripped out. Losing the A&E would be the thin end of the wedge.’
Ambulanceman: ‘We’re under siege – please get behind this crucial battle’
Today’s ambulance crews are under siege. As a registered paramedic who has worked on front line ambulances in Hertfordshire since 2000, I’ve seen crews become hopelessly stretched.
Now the service is being stretched still further by A&E closures. For every one that is shut down, ambulances have to drive much further, to more distant hospitals. That makes them unavailable for longer periods.
So inevitably, patients – some of them critically ill – are having to wait much longer between 999 call and final handover to casualty department care. The Mail on Sunday recently reported that in Newark, where there used to be an A&E on the doorstep, it now takes nearly two hours on average between callout and handover. That comes as no surprise to me.
There are other consequences. The fewer A&E departments that remain are getting inundated with ambulances arriving en masse. They can’t cope, so crews stand idle in hospital corridors, their patients still on trolleys.
Yet at the same time, the crews are facing cuts in their budgets. Throughout the UK, ambulance trusts are laying out plans for cuts of four per cent a year over the next five years. For my former employers, the East of England Trust, this means losing £50million. The situation is unsustainable. The service will break.
The problems are starting to manifest themselves already, as the number of calls increase and ambulances are often left ‘out of position’ after attending emergencies in places whose own ambulance cover had been depleted.
Meanwhile, ambulances that can both stabilise and convey a patient are being reduced. They are being partly replaced by rapid response vehicles, cars with a single paramedic. This system often results in a lone paramedic stranded at an emergency with no backup nearby.
As A&Es close, this will get worse. Let’s imagine one scenario in my old patch – a serious traffic accident in Cheshunt.
Before the Queen Elizabeth II Hospital in Welwyn Garden City, closed its A&E to ‘blue light’ emergencies, it would have taken a local ambulance maybe ten minutes to reach the scene.
The crew stabilise their seriously injured patient and take him to QEII 15 minutes away. He starts receiving hospital treatment within 30 minutes of the 999 call. Then the crew readies the ambulance for the next call, making a total turnaround of less than hour.
Today, the nearest resource would most likely be a lone paramedic in a rapid response vehicle. She arrives seven minutes after the 999 call, but can’t take the patient anywhere – and has to wait 35 minutes for an ambulance from Watford.
They can’t take the patient to the QEII any more, so go to Stevenage, 35 minutes away. They alert the hospital en route, but when they arrive there is a queue of ambulances and no space on the ward.
The crew jumps the queue because the patient is critical, but he doesn’t start to get treatment until 90 minutes after the accident. It’s another 30 minutes to ready the ambulance for the next call… but they’re 40 minutes from their usual base.
Hence, a single A&E downgrade has doubled the time an ambulance takes to deal with one emergency. Yet resources have not been doubled to account for it – in fact, they are being reduced.
The quality of patient care has been reduced, and there is increased pressure on both ambulance and A&E staff.
Finally, we have the growing requirement to provide blue-light transfers from urgent care centres to the A&Es which do stay open, and to specialist centres such as stroke and cardiac units.
In theory, patients who arrive safely at such facilities will receive better treatment, but if the organisation responsible for getting them there can’t do so in good time, the risk to patients is unavoidably increased.
Last month, a back injury forced me to step down from a career in which I was proud to have helped thousands of people. I have had the privilege of delivering babies and bringing people back from the brink of death. Like every ambulance worker, I always used everything in my power to help ease physical suffering and troubled minds.
Today’s ambulance trusts face an impossible task – and A&E closures are only making things worse. The only real answer is for the public to take greater responsibility – as The Mail on Sunday’s campaign is urging them to do. The state of the ambulance service is no longer somebody else’s problem. It is everybody’s problem.
Patient deaths go up 20 per cent every ten miles travelled… so bigger isn’t better for most families
The argument for closing some small, local A&Es is simple: centralisation of care into fewer, larger units will mean better care.
It’s argued that better care in these A&Es will more than compensate for the extra risks of travelling further. But what is meant by ‘better care’?
There is pretty strong evidence that specialist care that isn’t available everywhere really can improve outcomes for three emergency conditions: certain serious injuries – particularly head injuries – certain types of stroke, and heart attacks.
These patients get better outcomes because some centres can provide care which is different from, and better than, routine care.
At some centres, patients with strokes caused by blocked arteries in the brain can be given drugs which cannot be given at local centres.
And specialist trauma hospitals with 24-hour neurosurgery can manage serious head injuries in ways that other hospitals cannot.
The evidence is that this leads to better outcomes, and most researchers believe it is often worth the risk of travelling further to get these patients to the specialist centres.
However, all the other patients attending A&Es will get the same care wherever they go.
And for them – the large majority of emergency patients – there is no reason to suppose that their care at a more distant or specialist centre will be better.
There’s certainly no evidence that it is. For them, the outcome is likely to be worse.
Even life-threatening conditions such as poisoning, drowning and asphyxiation, acute asthma attacks, and anaphylactic shock are treated in the same way in small hospitals as in our grandest teaching hospitals.
These patients need care as quickly as possible, not different care.
Of course if ‘bigger is better’ then centralising care might lead to doing the same things better. However, there is little evidence that bigger is better, except in certain specialist procedures such as heart surgery.
For services such as intensive care and A&E there is no evidence.
So for most patients, travelling further to more distant centres has no upside: only a downside caused by the extra time to get to A&E.
‘So what happens if you close a local A&E? You force everyone, whether or not they need special care, to go further and be treated later.’
First, extra time in the back of the ambulance means extra risk. This could only be avoided if the back of an ambulance was as safe as A&E, and no matter how good paramedics are, no one would claim this is true.
Secondly, in emergency medicine, treatment is usually more effective the earlier it is given.
A dramatic example of this is a drug given in A&E which reduces deaths from bleeding injuries by 15 per cent compared to a placebo, but if it is given one hour later the reduction is only one per cent.
A one-hour delay would mean many more deaths.
When my colleagues and I looked at outcomes of more than 10,000 serious 999 calls, we found that roughly speaking, the number of patients who died increased by 20 per cent for each extra ten miles travelled by road to hospital.
These extra deaths were particularly pronounced for respiratory conditions.
So what happens if you close a local A&E? You force everyone, whether or not they need special care, to go further and be treated later.
Some patients get a different and better treatment, which can be worth it.
The majority get the same treatment later, and their care is worse. This doesn’t seem to be a rational basis for closing local A&Es.
So what should we do to improve the care of emergency patients?
The first option is for ambulances to bypass the local hospital just for those patients that can benefit from care not available there.
Patients with serious injuries, possible strokes or chest pain, could be taken directly to the specialist centre, and all other patients could continue to go to the local centre. In some places, this is being attempted already.
If it is necessary to close some A&Es, for example because there are not enough suitable staff, the second option is to accurately measure performance and close the worst.
If we had evidence that any A&E was providing poor care, whatever its size, then there would be a rational argument for closing it.
Accurately measuring performance is difficult, but the problems can be solved.
Should we reorganise our A&E departments? Yes I think so, but my advice would be only to close units which are demonstrably and consistently providing poor or unsafe care.
Head attacks muddle-headed attempt to get more of “the poor” into British universities
Christopher Ray, chairman of the Headmasters’ and Headmistresses’ Conference, which represents more than 250 top independent schools, said that the use of “positive discrimination” in the admissions system risked acting against pupils from the fee-paying sector.
Currently, universities are expected to draw up targets to boost the number of pupils admitted from state schools and poor families.
But Dr Ray, High Master of Manchester Grammar School, said the process was not sophisticated enough to take account of pupils from selective state grammar schools or comprehensively-educated teenagers sent to private tutors by their parents.
The system also risks overlooking the thousands of pupils from the poorest families given bursary places at independent schools, he said.
The comments come amid continuing concerns over the use of “social engineering” in university admissions.
All institutions in England are expected to draw up “access agreements” setting out measures designed to create a more balanced student body in return for the power to charge up to £9,000 tuition fees.
As part of the document, they must set targets to boost participation rates among pupils from state schools, deprived families and neighbourhoods with a poor track record of higher education.
Prof Les Ebdon, the head of the Government’s Office for Fair Access, has told leading universities to set the most “challenging” benchmarks.
This week, it emerged that the number of private school pupils admitted to Cambridge had dropped by 18 per cent to 892 in just 12 months as the proportion of state-educated entrants rocketed to a 30-year high.
Speaking ahead of HMC’s annual conference in Belfast next week, Dr Ray said: “Without positive discrimination, we wouldn’t have had the huge advances we’ve had on the disabled front. But actually, in their case, they’ve been trying to change attitudes.
“Here, it’s not attitudes that are being suggested, it’s just straightforward favouring of those who’ve not been able to perform as well, due to the failings of the state sector, on the whole.”
He insisted there was “no evidence” that independently-educated pupils had so far been systematically denied places by the new admissions rules.
But he said the system of “positive discrimination” was inadequate when it came to properly differentiating between pupils.
Dr Ray said it struggled to give credit to teenagers on full bursaries at his private school “where reading books in the home is not part of the culture [and] where no-one else in the family has been to university”.
He also said that targets to increase state school admissions risked giving unfair advantages to those educated at highly-selective grammar schools or teenagers from state comprehensives who receive private tuition in the evenings and weekends.
“The tutoring industry is huge, not just for 11-plus but for GCSE and A-level, and I don’t understand or see how any system, however fleet of foot or focused, can actually get to that level of scrutiny,” he said. “Would you actually ask your child to declare on his UCAS form that he had been tutored?
In separate comments, Dr Ray also criticised politicians who repeatedly attack private schools for failing to do enough to justify their charitable status.
This summer, Alan Milburn, the Coalition’s social mobility tsar and former Labour cabinet minister, said schools had to do more than simply opening their playing fields.
Dr Ray said: “It is a typical misrepresentation of the independent sector, hoping to gain a political advantage. I understand why politicians feel the need to do that but, of course, if they entered such answers on examination scripts they would be quite fairly be graded fail.”
New British CO2 tax will double UK electricity bills
There’s a nasty shock in store for the British householder when a new ‘carbon’ tax comes into force
Fast approaching, if largely unnoticed, is yet another massive shock the Government has in store for us with its weirdly distorted energy policy. It is surprising to see what an abnormally high proportion of the electricity needed to keep our lights on has lately been coming from coal-fired power stations. Last Wednesday evening, for instance, this was over 50 per cent, with only 1.3 per cent coming from wind power. Yet by next March, we learn, five of our largest coal-fired plants, capable of supplying a fifth of our average power needs, are to be shut down, much earlier than expected, under an EU anti-pollution directive.
One reason why these plants are being hammered through their remaining quota of hours allowed by the EU is that a new UK tax comes into force next April, which aims to make fossil-fuel power significantly more expensive. In 2010, George Osborne announced his intention to impose, from April 2013, a “carbon floor price” of £16 on every tonne of CO2 emitted by British industry, rising to £30 a tonne by 2020 and £70 a tonne by 2030.
An explicit purpose of this tax is to make the cost of electricity from fossil fuels so uncompetitive compared with “renewables” that it will, in the Treasury’s words, “drive £30‑£40 billion” of investment into “low carbon” sources such as wind and nuclear. On paper, the effect of Osborne’s new tax on our electricity bills looks devastating.
Using the latest figures from the Department of Energy and Climate Change (DECC), our power plants burnt 40 million tonnes of coal in 2011, emitting 116 million tonnes of CO2. They also generated 175,000 gigawatt hours from gas, at just over half a tonne of CO2 per gigawatt. At £16 a tonne, this CO2 would cost £3.5 billion – on top of our total current wholesale electricity cost of some £19 billion. Thus the new impost would represent nearly 20 per cent added to our electricity bills next year, and would almost double them by 2030.
Some of this, however, we already pay through the EU’s Emissions Trading System (ETS), which counts towards our £16 floor price. Osborne’s calculation in 2010 was that, initially, we would have to chip in less than an additional £2 per tonne to make up the £16 price. (The ETS price at that time was predicted to continue rising towards £40.) Since then, however, with falling demand due to the EU’s recession, the price of EU carbon permits has fallen dramatically. To reach the initial £16 level, the Treasury says we will now have to pay nearly another £5, making our electricity significantly more expensive. But since it made that guess the EU price has slipped still further, to well under £6 – leaving a gap of £10 a tonne to be made up by Osborne’s tax, rapidly rising every year thereafter.
Thus, to meet that tax level in the years after 2013, we in Britain will have to pay electricity bills soaring to a level far higher than any others in Europe. All this is to promote the building of thousands more heavily subsidised windmills, which will in turn require us to build more gas-fired power stations to provide back-up for the constant fluctuations in wind speed. And these will be paying Mr Osborne’s fast-rising tax on all the CO2 they emit, with the bill to be picked up by the rest of us on a scale which, within 18 years, could alone almost double the cost of our electricity.
In short, the Treasury has made an incredibly damaging miscalculation. Even if there is little chance that our Energy and Climate Change Secretary, Ed Davey, could get his head round such lunacy, perhaps someone might lay out for Mr Osborne the bill that his delusional new tax is going to land us all with.
British government attempts to bypass hungry local bureaucracies over residential construction are too little too late
The Government’s recent announcements on changes to planning are to be welcomed, but they represent a very half-hearted attempt to reduce the disincentives to construction (it’s a shame that they also came with dollops of more spending as well). Contra the Local Government Association’s propaganda, it is quite clear that it is the planning system which is the principal contributor to Britain’s dire shortage of housing. As I recently pointed out, it is this shortage which explains the lack of affordability of housing – both for purchase and rentals, not to mention the vast economic distortions which this constrained supply creates. These initiatives – where they are not entirely misdirected – are tiny compared to the scale of the problems.
But what government giveth, government also taketh away. This take away is in the form of the Communities Infrastructure Levy, which was introduced in 2010 (stemming from the Labour Government’s 2008 Planning Act) and is gradually being implemented. The CIL permits local councils to levy an infrastructure charge on developers in order to fund the demand for new infrastructure created by their development. Unfortunately, CIL does not replace the pre-existing Section 106 Agreements under the Town and Country Planning Act (1990) – often used to subsidise ‘affordable housing’ – but instead is supplementary. The Section 106 Agreements were rather arbitrary whereas the CIL will at least have the benefit of transparency as it is simply levied on a pre-determined rate per m2.
According to the Department of Communities and Local Government’s information: ‘Under the system of planning obligations only 6 per cent of all planning permissions brought any contribution to the cost of supporting infrastructure, when even small developments can create a need for new services. The levy creates a fairer system, with all but the smallest building projects making a contribution towards additional infrastructure that is needed as a result of their development.’ Immediately we should observe an issue; if the CIL intends to increase the amount of contributions derived from developers then this can only represent a further disincentive to developers to build housing. Whilst there is great stress laid upon the need for Councils to balance the CIL – the rate of which is determined by the individual Councils themselves – with the economic viability of development, this effectively means that Councils can determine how much profit any developer can make. The CIL is expected to derive an extra £1billion p.a. by 2016 for spending on infrastructure – which must represent an additional tax of £1billion on development. This hardly seems likely to encourage something that is in short supply and seems to run contrary to the Government’s own stated policy aims.
There are also some rather more unforeseen and pernicious effects of the CIL, as recently reported in the Sunday Times [Homes section 2/9/2012]. Firstly, certain councils appear to be using the CIL and Section 106 to raise revenues in the face of tightening from central government and the decline of the volume of housebuilding, especially as the rates are discretionary.
However, like most regulation and taxation the CIL will hit the small man the hardest – in this case, self-builders. As the CIL is levied on any building over 100m2 it may render many self-builds financially unviable according to the postcode lottery of charges. In the worst instance Wandsworth has set rates at over £500/m2 – given that the average self-build is 200m2 the additional costs are hugely disproportionate to the infrastructure demands of any one household. Again, encouraging self-build was encouraged by the Government, particularly by out-going Housing Minister Grant Shapps. Whilst self-builds account for less than 10% of UK house build, disincentivising them is hardly going to help our dire housing situation.
Of course, there is much more that could be said here regarding the distortionary impacts of government control of infrastructure and planning on the housing market and the resultant difficulties the UK experiences in providing sufficient supply of housing. In this limited space it is sufficient to say that this is an ill-conceived policy that should have been scrapped by the incoming Coalition Government. Instead, it is being turned into a means of making up the shortfalls in council funding at the expense of further residential construction. What we have here is a classic but all-too-typical case of Governments advocating and attempting to stimulate via spending a desired behaviour in one area whilst at the same time Government is disincentivising the very same behaviour by another method. Additional infrastructure construction – if it must come from Government – should instead come from existing budgets by eliminating the vast amount of wasteful spending that local Government currently engages in.