FrontPoint Systems Ltd

The claim that nearly half the A&E departments in the country are under threat has people up in arms.

“Current Department of Health and strategic health authority guidance suggests that, to be viable in terms of patient need, patient safety, staffing numbers and clinical training requirements, a full A&E department in the future would need to be supported by a catchment population of between 450,000 and 500,000 people.”

So where does this figure of 450,000 come from?

A report published last year by the Royal College of Surgeons recommended that the minimum catchment population of a fully resourced A&E department should be at least 300,000. But there is debate about whether catchment areas alone should be used to allocate NHS services. Local geography, healthcare needs and staffing levels may have to be taken into account.

Common sense I would have thought.

A Department of Health spokesman said there was no such official guidance from his department. “It is absolute rubbish to suggest that we are demanding the closure of A&E departments.

But he admitted that the recommendations were taken from a report by the Royal College of Surgeons supported by Sir George Alberti, the former director of emergency care. He recently recommended the closure of an A&E department in North London. The remaining two A&Es serving the area will be left with catchment populations of 450,000 each.

There is a difference between densely populated north London (not that I am in possession of detailed knowledge about the area & hence am not commenting on the specific merits of that particular proposal) & the greater geographical spread in Surrey, not just in matters of distance but also in terms of demand for services. Surely decisions at SHA & PCT level do not just parrot “guidance” but involve public health experts & frontline clinicians in the design of services? I have been increasingly concerned at the lack of clinical involvement in these decisions.

The RCS has clarified that it is only asking for major trauma facilities to be concentrated.

Dermot O’Riordan, of the Royal College of Surgeons, said: “Very major trauma cases with multiple injuries like road traffic accidents are more likely to survive at specialist centres, but local emergency departments should stay open to focus on what they do well.”

Yes, but how do you get them there in time? Are we prepared to invest in an increase in HEMS / med-evac helicopter capacity? Or will existing ambulances simply have to travel further? There is a lot more to this & the intemperate closure of existing services without having appropriate validated replacements in place is rather dangerous.

Though the argument is made that time is not an issue.

Ambulance crews are now well-trained paramedics able to stabilise patients and give emergency treatments. Except in rare cases, the time taken to reach hospital is not critical.

“Long ambulance journeys do not lead to more deaths,” said Sir George Alberti, the former national director for emergency access.

Specialist A&E units, fewer in number and therefore farther for most people to travel, would save more lives, the Government asserts.

So do we “scoop and run” or “stabilise and treat”? The fashion varies over the years (the discussion of the treatment recd by Diana Princess of Wales was a case in point) & I am not too sure that members of the ambulance services would claim to be capable of doing what is suggested. Especially since I have highlighted earlier the move to replace one of the paramedics on a two man crew with a driver / technician with 8 weeks training. It is called integration, or one hand knowing what the other is doing.

Yes, we need to be more flexible with ambulance protocols, not just dumping patients at the nearest hospital. But these reconfigurations need to be based on the practical, not a theoretical possibility.

The doctors either disbelieve the claims, or use a more subtle argument to justify retaining an A&E. They say that loss of emergency services risks destabilising the hospital, and reducing its capacity to do other things.

An A&E requires the services of orthopaedic surgeons. Without an A&E, it is harder to sustain the necessary numbers, and the ability of the hospital to do elective orthopaedic operations is diminished. Costs rise, and it becomes uncompetitive. So closure of the A&E can have knock-on effects.

They ask why these clinical arguments for closures have emerged at a time when the NHS is short of money. The coincidence suggests that cash, and not best practice, is driving the changes.

I have to concur.

So who came up with this?

This was endorsed by the National Leadership Team, a body that advises the Department of Health, and a document produced by a local primary care trust described this as “national guidance”.

Either this is an oversimplification of the output from the advisors (with all caveats removed) or they have become remote from the day to day struggle to provide care & do not any longer represent professional consensus.

The DoH frequently sends out “guidance” of this nature procured from a variety of sources. It is incumbent on PCTs & SHAs to apply their minds to these documents & not take them as gospel. That is the whole reason why the professional component of NHS structures needs to be strengthened.

The proposals in the expected update of the Human Fertilisation and Embryology Act 1990 are highlighted in the BBC with implications for abortion services as previously mentioned.

What palliative care? I would be hard pressed to find many such services.

I have my differences with the hospices as I feel that they give up too easily. Patients are promised visions of personalised inpatient care in clean comfortable facilities if they decide to cease intensive treatment, as compared to the mad bad & dangerous world of acute hospitals.

But my argument is that every patient should be receiving such care, not just the ones at deaths door & hospices should not force patients to make such a choice, especially given the advances in medical treatment. And children’s wards are an idyll compared to adult wards.

The speculation over Isoft’s future takes up more space with questions being asked about IBA’s health.

IBA’s full-year results show very poor conversion of profits into cash. In the year to June 2006, profit after tax was A$15.3m (£6.4m), while cash inflow was just A$421,000. Profits after tax in 2005 were £14.4m, but the company recorded cash inflows of £6m.

I presume that the advisors at both ends earned their money having examined the books in detail but will wait to see what comes out.

A move to Sydney is also mentioned.

The group at the heart of the NHS software upgrade will move to join its suitor, IBA Health, in Sydney after it struck a £233 million deal to create the biggest healthcare IT company outside the United States.

Size isn’t everything. All companies have to start small somewhere & it is their products that determine prospects & reputation. Isoft’s current products are at-least 2 generations old & need to be replaced soon.

Especially as the BMJ highlights the dangerous state of information systems currently.

One hospital IT manager told researchers: “It’s been urgent that [the system] is replaced all the time I’ve been here, which is about three and a half years … It is a clinical risk.” Another said the system still being used at his hospital was “not just obsolescent, it’s obsolete”. The trust had had to buy computer parts on eBay and get them shipped from the US.

The last four years have been a distraction & a disappointment. But trusts have put off any IT plans since at-least 2001 with the expectation that the DoH would deliver, strangling any innovation in their own backyards in the meantime. This is a failure not just of CfH but also of business planning at the various trusts themselves.

The expected public sector summer of discontent comes closer to reality as the RCN vote to ballot their members for strike action as promised at their annual conference.

The RCN met on Wednesday to discuss their options after an emergency motion passed unanimously at the RCN conference in April called on the government to implement a full 2.5% pay rise as recommended by the independent pay review body.

The Royal College of Nursing ballot will ask NHS members whether they want to be balloted on what would be the first ever national industrial action.

The first move to coordinate strike action was announced yesterday when Dave Prentis, general secretary of Unison, the country’s second biggest union, released a letter saying it and the Public and Commercial Services Union (PCSU) should coordinate industrial action in hospitals, health centres, Whitehall departments, jobcentres, courts, museums, art galleries and the coastguard service.

The PCSU conference voted unanimously to escalate strike and industrial action in Whitehall. There have already been two one-day strikes, with the Cabinet Office acknowledging that 119,000 people took part in the last action on May 1, which hit jobcentres, tax offices, driving tests, courts and museums and art galleries.

And what of medical training, with the second day of the judicial review scheduled for today in the High Court?

Thomas de la Mare, representing Remedy in the High Court, said key decisions with a direct and serious impact on doctors were being made “without any form of notice or consultation”.

In a court packed with junior doctors and their supporters, he said MTAS was now “so conspicuously unfair as to amount to an abuse of power”.

And he said it was mystifying why the British Medical Association, the doctors’ trade union body, was not supporting its call.

Ah, but the BMA & the Academy of Medical Royal Colleges are busy brown-nosing.

We restate our support for the Chief Medical Officer and his role in improving junior doctors’ training. He pioneered the principles underlying the reform programme. Serious though they have been, it would be a far-reaching shame if those principles were obscured by recent problems with the online application system.

The problems with the applications were just the tip of the iceberg. Unvalidated educational theory is being forced down an unwilling profession in the form of the current implementation of MMC. Yes, it would be nice for example to cut the period of postgraduate training from 12 years to eight but to do so without increasing the educational content of those eight years is not realistic & can only deliver decreased standards. First show concrete proposals to improve the quality of training & then we can talk about cutting the time required.

There are a number of letters related to healthcare in the Telegraph today with Monitor coming on board to defend it’s handling of the Royal Brompton.

The application from the Royal Brompton and Harefield NHS Trust is being dealt with in exactly the same way as is any other applicant’s, and the standards required of it are no different. The assessment is in process and no decision has been made.

William Moyes, Executive Chairman, Monitor, London SW1

MTAS & budgets get a mention too.

Sir - You report (May 16) that the notorious online application process for junior doctors is to be scrapped. Unfortunately, as you imply, this will do nothing to alleviate the present crisis. The appointments of doctors to thousands of posts, due to start on August 1, have yet to be made.

This week, doctors are being called for interview with no more than 48 hours’ notice. Indeed, I know of candidates being telephoned abroad to attend for interview the next day. Regrettably, this callous approach by administrative staff to dedicated young men and women has prevailed in the NHS for some years now.

Thousands of doctors will have less than two months to prepare for their next job. Many will have to move considerable distances to find new homes, with consequent serious effects on their spouses’ careers and family life. Other well-trained physicians and surgeons will simply be unemployed.

Professor Robert Rubens, London SW19

The view from the gallery:

Immediately after Mr Prescott, Patricia Hewitt came to the Dispatch Box to answer an emergency question about junior doctors put down by the Tories. Miss Hewitt was, if possible, even more useless than Mr Prescott.

She is another member of the doomed and discredited crew who no longer even pretend to have any kind of control over the ship of state.

Simon Carr

The day developed a theme. Before the debate on Home Information Packs, the Speaker allowed an Urgent Question on Patricia Hewitt. The question was: “Why on earth is she still Minister of Health?” I thought the answer was obvious but Andrew Lansley muddied the waters sufficiently to let her escape into the murk.

The computer isn’t that important to the doctors’ training places fiasco. The first rule of computing is: sewage in, sewage out. It isn’t the computer saying that one failed interview prevents you ever becoming a consultant.

No, it’s Mrs Hewitt saying that, or someone very like her. It is she who should pick up the can of sewage and carry it outside, closing the door behind her.

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This entry was posted on Thursday, May 17th, 2007 at 8:57 am and is filed under Clinical, Management, Medical Informatics, NHS, Politics. You can follow any responses to this entry through the RSS 2.0 feed. You can leave a response, or trackback from your own site.