QE2 Hospital A&E from kenjonbro Flickr Photostream

Contrary to popular belief, attendances have stayed static since 2003 in what the Department of Health calls type 1 units – the big hospital-based A&E departments. Indeed, not a week passes without a news story about A&E departments: seven threatened with closure in London; ambulances queueing around the block as patients wait for hours to be seen; insufficient staffing levels; high spending on locums. Amongst all of this, emergency medicine is a tiny speciality, with fewer than 4,000 doctors in contrast to 32,000 GPs – and yet it consumes an inordinate amount of airtime. Why?

A&E is the canary in the coalmine; it tells the story of what is going on elsewhere in the service. Cuts, competition and the fight for survival are at the heart of the story. Over the past 20 years many hospitals and A&E departments have been closed, usually as part of private finance initiative projects. It is the high price of repayments on these PFI agreements that drove these closures, not changing patient needs.

Another area of rapid change is in the number of hospital beds. They have been lost at a rapid pace, not because there isn’t a need for them, but because the government is either paving the way to divert patients to the private sector in the future, or removing NHS services to allow foundation trusts to generate income from private patients (e.g. the Health and Social Care Act lifts the cap on private income to a level of 49%). Over the past two and half decades successive governments have closed over 50% of NHS beds. In 2013/14 there were 135,000 NHS beds compared with 297,000 in 1987/88. England now has one of the lowest number of beds in Europe and the highest bed occupancy – over 100% in some specialities – which means medical patients are being displaced on to surgical wards, which in turn leads to cancelled elective surgery and increased waiting times.

And without beds, pressure builds in A&E. Reductions in one area impact directly on other associated areas, and this is what we are seeing in A&E.  Yet the government is still responding to the tidal wave of need with demand management measures i.e. cutting budgets and services, with plans to close more hospitals and to cut more A&E departments. The net result is that our hospitals and our A&E departments are at full to bursting, they are saturated and cannot accommodate any more patients and so seriously ill patients are being turned away. But no one is monitoring or measuring this: community health councils, once the voice of local people, have long since been abolished, and there is no census of emergency departments.

At the same time, the government is closing services in primary care and local authorities are axing services in social care. GP out-of-hours services are no longer functioning as they should and neither are social services and community support. It is now impossible to see your own GP out of hours, at one time this state of affairs would have been unthinkable. Where, out-of-hours services do persist, they are increasingly operated by private corporations, with GPs no longer in control. More pressure builds.

The Labour government set up walk-in centres and minor injury units as an alternative to GP out-of-hours services. But now these are also being closed; of the 230 opened under Labour, 53 have shut down in the past three years. Contrary to popular belief, attendances have stayed static since 2003 in what the Department of Health calls type 1 units – the big hospital-based A&E departments. The increase has occurred in type 2 and 3 units – the minor injury and walk-in centres – and so can be explained by the decline in GP out-of-hours services. So why are alarm bells only sounding in the big A&E departments?

Since the Health and Social Care Act removed the duty on the secretary of state to provide universal care, it is every hospital for itself, competing against each other in a market place; there is no planning, only forecasting for income and sales. But A&E is expensive and, like geriatric care and children’s services, the price the government pays may not meet the costs. Hospitals would rather concentrate on niche markets like cancer, cardiac and elective care, especially if they can raise some private income at the same time. Markets don’t like risk or uncertainty.  Thus the new NHS pricing model works against A&E. Professor Keith Willett, the man leading NHS England’s review of emergency services, has described the model as “wrong”, and says it has led to an “adversarial” relationship between hospitals. But it is not just between hospitals – it is also within each hospital, as speciality fights speciality for survival. This means specialisms lobbying for resources, and trying to raise their voices above all the others in order to be heard. At the moment A&E is shouting the loudest.

About the Author: Allyson Pollock is professor of public health research and policy at Queen Mary, University of London. She has been a vocal critic of the ongoing reform of the NHS. Her research interests include globalisation; privatisation, marketisation and PFI / PPPs; health services; regulation and trade; pharmaceuticals and clinical trials; and childhood injuries.

This post was adapted from an article that originally appeared in The Guardian.