Reconfiguration of surgical, emergency, and trauma services in the United Kingdom

To find the royal colleges proposing that acute inpatient care in the United Kingdom should be provided in fewer, larger, better equipped, and better staffed hospitals is not unusual. What would be unusual would be to find a government two years out from a general election rushing to implement such advice. The Senate of Surgery of Great Britain (comprising the four surgical royal colleges, the dental faculties, and 10 surgical specialty associations) has published a policy paper that seeks to speak with a single voice for the surgical community (www.rcpsg.ac.uk/recreport.htm).¹ This policy paper signals a wish for a debate on this controversial topic and a wish to participate.

These surgeons want a lot—and not for the first time, and not just the surgeons. The senate suggested something similar in 1997, but it did not happen.² The Royal College of Physicians wants to phase out acute emergency admissions from isolated smaller units and transfer the work to properly equipped and staffed larger units.³ The arguments are cogent and extensively made—in surgery, medicine, paediatrics, and maternity care. The impending need to comply with the European Working Time Directive—a regulation of the European Union limiting a doctor's working week to an average of 56 hours, which comes into force in August 2004—is adding velocity to a general demand among professional advisory bodies to concentrate the medical workforce in fewer, larger, acute centres.

At this stage in the United Kingdom electoral cycle (with an upcoming election in which the NHS is guaranteed a central place among the issues), does anyone expect to see the rapid implementation of policies that will be perceived to “downgrade” the importance of perhaps 50 or more acute hospitals? When asked to take a tough decision, Richard Nixon was alleged to ask, “Does it play in Peoria, Illinois?” Badly.

Conditions for the new pattern set by the senate

• Must be acceptable to the public

• Make coordinated care from first presentation to rehabilitation and return to home possible

• All surgeons are to have adequate clinical experience and training opportunities

• Services are to be cost effective; the importance of outcome data is to be recognised

• Internationally accepted standards of surgery are to determine the reception of all surgical patients in all centres irrespective of size

• Complex surgical inpatients are to be treated in larger hospitals

Perhaps the senate's members will be in a difficult position for some time to come until one of two ways forward is cleared. Firstly, they could connect their ambition for greater centralisation of complex acute cases to the realpolitik of constituency affairs and provide the politicians with a means of winning votes by implementing them. The Kidderminster debacle will be fresh in all politicians' minds. (Kidderminster is a town in England that voted out both the local council and member of parliament and replaced them with single issue candidates dedicated to saving the local hospital.) Any local proposals for reconfiguration of hospital services will have to negotiate a substantial nexus of legal and political processes. The history of these consultations teaches us that public anxieties about losing local access to emergency services carries more political clout than professional logic. Maybe it is time for the colleges to explore this public psychology and find a way of connecting with it. Secondly, they could give deeper and wider thought as to how “managed clinical networks” could be introduced so that local emergency units can flourish while complex emergency cases can be swiftly funnelled towards appropriate specialist centres.⁴ According to evidence presented by the London Ambulance Service to the Turnberg review of London in 1998, perhaps only 35% of patients arriving via 999 calls are admitted to hospital. The document acknowledges the need to encourage “a flexible approach to working by consultant colleagues in different hospitals forming a managed clinical network.” This encouragement now needs to find its response at grass roots level in imaginative and practical proposals supported by these colleagues.

I have argued elsewhere that more work is to be done to evaluate how smaller local emergency units can work in tandem with more major centres of specialist care in a way that exploits the rapidity of access that a local unit brings while gaining the diagnostic leverage of specialist colleagues.⁵ If the price of moving the complex emergency to an appropriate centre of expertise is that this patient is accompanied by another nine or 10 patients who are not complex acute cases then another set of problems is launched.

This call by the senate for reconfiguration gives some valuable pointers as to where further policy work might be fruitful—the development of non-medical cadres, greater integration of the ambulance service, the development of information technology, and the involvement of the public. To these could be added the exploration of virtual diagnosis, the amalgamation of primary and secondary care in smaller communities, and the rotation of staff within clinical networks and between smaller and larger units.

Of one thing we may be certain. Any proposals to reconfigure acute emergency hospital services in the United Kingdom are going to be politically controversial and hotly contested.