The first part of the Keogh Report into urgent and emergency care was published last week. It claims it will lead a complete overhaul of the system it acknowledges is at breaking point.
The numbers of people accessing urgent and emergency care have risen year on year. Though there is little detailed analysis of what has caused these rise, the report cites an increased elderly population with complex health needs, difficulty accessing out of hours GPs, and the government raising expectations of the system by promoting a market style consumer ethos towards the NHS.
Keogh wants fewer people to access services, fewer people to go to hospital, and fewer people admitted for shorter periods.
These aren’t in themselves bad aspirations. People being informed and confident to manage their own health, and being able to access support locally in their community would be a good thing. But in the context of cuts, privatisation and marketisation of the NHS, these aims are likely to give the government the justification for further reducing publicly provided services.
Even at this early stage the Report is specific on the proposal that many A&E departments could be downgraded to urgent care centres, but is very vague on the increase in community based services it says are needed to replace hospital based care.
The report proposes increased support for self care, improving out-of-hospital urgent care facilities and designating certain A&E centres as major emergency centres to provide the most acute life saving care.
Again in theory these could be sound proposals. The problem is the reality of implementation in a system where community services are inadequate and hospital services have been designated too expensive and face cuts. The whole Report has cost-saving running through it. Any talk of alternative services in the current climate is code for privatisation.
Self-care in the report is defined as access to information and peer support patient groups.
Providing information is of course good, and peer support has been shown to be highly effective for those with chronic conditions. But with decades of the medical professions claiming elite status and not involving patients in their care, it will take a bit more than a few internet sites for people to really be able to make informed decisions about their health.
More information in this context can increase anxiety and demand on services. The talk of using symptom check technologies evokes visions of vulnerable people being monitored at home by machines.
The proposals for extended urgent care services are aimed at the millions of people who turn to A&E in non-emergency situations.
Proposals include an increased role for paramedics, who would act as “mobile urgent treatment services”, pharmacists and telephone based advice.
All well and good, as long as the extended roles of these services are resourced and backed up. A paramedic taking time to treat someone at home and make a patient feel confident that they don’t need immediate hospital treatment is possible, but not a cheap option.
It would need to be closely linked into the rest of the NHS, less likely to happen within an increasingly fragmented privatised ambulance service.
The report reports the evidence for centralised emergency treatment for certain conditions — some heart attacks, major trauma and strokes.
But the report uses this to advocate reduction of services at other hospitals.
The system of regional or area specialist services is already in place and maybe extended for other conditions, but this cannot be used to close down A&Es elsewhere without reducing access and bringing huge risks to patients in those areas as well as undermining local general hospitals — the argument was put powerfully by the Save Lewisham Hospital campaign.
Community campaigners will need to keep a close eye on these proposals. The health trade unions urgently need effective campaigns in defence of NHS services.
