NHS A&E
The NHS Institute for Innovation and Improvement (III) has produced a draft Directory of Ambulatory Emergency
Care. In this they recommend that most emergency patients admitted to hospital with certain
conditions should be treated in the community. They claim that 90% of current hospital admissions pulmonary
embolism, transient ischaemic attacks and deep vein thrombosis, and up to 60% of ectopic pregnancy and
patients with chest pain could be treated outside hospital.
The Institute of Public Policy Research (IPPR), quoting a medical paper, state that 500 additional lives
per year could be saved by having specialist techniques, such as angioplasty, available for treating
heart attacks. It also quotes the British Orthopaedic Association and the Royal College of Surgeons
who say that 770 extra lives would be saved if all trauma patients were treated at specialist centres.
The IPPR state that universal access can only be provided at a smaller number of specialist hospitals.
Both points are probably correct, as basic statements, but both will be used as reasons for closing
down smaller hospital A&E departments, such as at Ayr and at Monklands, though in both locations
the primary driving force is finance not patient care.
However there are major problems with both positions. The III case will require management by the GPs.
However it requires the skill and experience of a specialist gynaecologist to decide which patients
with ectopic pregnancy could be managed at home. It is impossible for GPs to have or acquire that level
of expertise. Also the accepted view is that for people to be an expert in a particular field they need
to have exposure to that type of case or operation many times every year. Again it is most unlikely
that GPs would have that level of exposure to all these conditions suggested. And for a person with
chest pain which may be an MI the diagnostic tests for confirmation and severity are not available in
General Practice.
The IPPR statement is clashing with that of the III. If it is important to treat heart attacks with
angioplasty, stents or other specialised measures, the decision is not one which can be left for a GP
to make in isolation. The other point not considered by IPPR, because not specifically mentioned in
their reference articles, is the risk of increased travelling time. The American army in Korea started
out with the same view as quoted by IPPR. Though the evacuations were by helicopter with on board paramedics,
the death rates were unacceptable and the American army had to invent their MASH units much nearer the
source of casualties. There the minor problems were treated, major ones which could wait were sent on
and others had their conditions stabilised before being sent onto the major unit. If this was found
to be the best management when helicopter transport times could be virtually guaranteed, how much more
important is it for land based travel in an ambulance. For example the Lanarkshire Health Board state
that the ambulance transit time between Monklands and Wishaw is only 20 minutes but ambulance drivers
themselves state that this is the best possible time, and that in rush hours it could be twice or three
times as long. The position is much the same in the case of an MI and on purely medical grounds it would
surely be better to maintain Monklands A&E since it is placed right in the middle of an area which
has one of the highest incidences of MI in the world. It is obviously unfair on ambulance paramedics
and unsafe for severely ill patients whether trauma or medical, for the medical responsibility for a
case during long transport times to be left to a paramedic.
The articles quoted by IPPR are correct but they need to be supported by a network of A&E units
which can perform the role of the MASH units. The academic pundits in IPPR and III seem to be ignorant
of the lessons from Korea. It would of course be essential that the “MASH” A&E units
had good contacts and relations with the superspecialist centres and did not try to hold on to patients
who would benefit from specialist services unavailable in their own hospital.
EVAN LLOYD
Consultant Anaesthetist. Edinburgh