Hospital cash crisis "manufactured by government"

That's one of the radical conclusions reached by hospital campaigning group KWASH in its response to the "discussion document" at the heart of plans to downgrade local hospitals.

The South East Coast Strategic Health Authority published its 'Creating an NHS fit for the future' document in the Spring, a consultation outlining a shake-up of health services.

Now campaigners have joined with consultants at Worthing and Southlands Hospitals to release an in-depth, 'evidence-based' response.

See the full text below:

"Introduction: This response has been the result of exhaustive reading and research by several Consultants at WASH who are concerned by:

a) Activity projections

b) Rationale for major changes in the settings of healthcare

c) Changes proposed in settings of healthcare

that have been proposed by the SHA. The major difficulty has been extracting the relevant information from the huge mass of paperwork that is produced by the DoH. Key documents quoted throughout the various SHA statements include:

'¢ Settings of care (various dates 2006), Surrey & Sussex SHA

'¢ Creating an NHS fit for the future discussion documents, Surrey & Sussex SHA

'¢ Our health, our care, our say: a new direction for community services, DoH January 2006

'¢ Making the shift: Key success factors, A rapid review of best practices in shifting hospital care into the community, University of Birmingham Health services Management Centre, July 2006.

'¢ Your health, your care, your say, prepared for DoH by opinion Leader Research, Jan 2006

Overview:

'¢ The current WASH financial problems are the result of a 'manufactured' budget deficit created as a consequence of central government belief that the South of England is an over-resourced Health Economy.

'¢ It is inconceivable that any hospital in the South of England could cope with the huge volume of elective and emergency medicine and surgery, which take place at WASH, if acute services at Worthing hospital are withdrawn.

'¢ Although the public are interested in new and innovative ways of providing hospital services in community settings (including diagnostic tests, etc), many fear that the Government's proposals are a means to closure of local hospitals via the 'back door'.

'¢ The quality and scope of evidence to support shifting hospital care into the community is lacking, and it should not be assumed that this shift will reduce costs. Merely relocating secondary services or specialists into primary care settings will not reduce demand on hospital resources.

'¢ The local population can be reassured that any concerns expressed by the SHA regarding staffing levels at WASH as a consequence of the EWTD, are unfounded.

'¢ Closure of acute services at Worthing Hospital will result in patient deaths as a result of the interhospital transfer of sick patients, and will be very expensive. There are safety concerns for telephone triage in the community by nurses and paramedics, and calls for further safety evaluations have been advised.

1. Funding for the NHS in West Sussex '“ Why is WASH in debt?

References: (a)Allocation of resources to English areas (AREA), Sutton M et al, Report to DoH

(b)Resource allocation: Weighted Capitation Formula, 5th edition, DoH 27/05/2005

(c)NHS Funding & Allocation Policy, Surrey & Sussex SHA, Barry Elliott, Director of Finance, May 2006

'Since 1971 NHS funding has been allocated on the basis of the relative

needs of the population served. The weighted capitation formula was

introduced in 1995 following development by the University of York. The

formula has been regularly updated since then and in November 1998 was

subjected to a wide-ranging review to reflect, inter-alia, the requirement to

allocate resources direct to PCTs and with a new objective 'to contribute to

the reduction in avoidable health inequalities'. A new formula was

introduced for 2003/04 incorporating better measures of deprivation and

taking account of unmet need.' (c)

'Any formula, particularly one that relies on 'proxies' as measures of certain

components (eg mortality rates as a measure of morbidity), will always be

open to challenge. Over the years there have been numerous debates

about the various elements of the formula and the relative weightings

attached to these. It is for this reason that the formula has been

consistently reviewed and revised. Responsibility for this rests with the

Advisory Committee on Resource Allocation which advises the Secretary

of State for Health on the distribution of resources across primary and

secondary care to ensure that these fully reflect local population need and

operate as fairly as possible. Members include academics, NHS

managers and GPs. The Committee meets quarterly and is supported by

a Resource Allocation Technical Advisory Group.' (c)

Interestingly there are currently calls for expressions of interest into NHS resource allocation research to review the need formula again! The components and weightings within the capitation formula are:

a) Hospital and Community Health Service Component (HCHS) = 77.4%

b) Primary medical services = 8.8%

c) Prescribing = 13.2%

d) HIV/AIDS = 0.6%

HCHS:

a) Age related need:

b) Additional need: (over and above that accounted for by age)

'¢ Acute and maternity '“ variables recommended by AREA report:

i. SMR under 75 years

ii. Proportion of low birth weight babies born

iii. Standardized birth ratio

iv. Education domain

v. Proportion of age 75+ living alone

vi. Income domain

vii. Nervous system morbidity index

viii. Circulatory morbidity index

ix. Musculoskeletal morbidity index

'¢ Mental health

'¢ Geographical cost (principally staff costs and based on variations in wages in private sector '“ some NHS trusts face higher indirect staff costs due to recruitment and retention difficulties, use of agency staff etc)

'¢ Emergency ambulance cost adjustment (e.g rurality index, case-mix affect)

'The weighted capitation formula is used to calculate an individual PCT's 'fair share' of available national resources. This fair share or target allocation is then compared to a PCT's current actual allocation to produce

the 'distance from target'. This is the amount by which a PCT is assessed to be either receiving more or less than its fair share of available national resources.' (c) For 2006/7:

'The capitation position of PCTs in Surrey and Sussex is such that even a significant change in the formula will at best reduce the extent to which most PCTs are above their 'fair share' target. It is highly unlikely that any

change in the formula would result in any additional resources being received by the majority of PCTs in Surrey and Sussex.' (C).

The pace of change policy has been determined for next 2 financial years and no PCT will receive less than 8% growth per year (minimum level of growth). Surrey & Sussex PCTs will receive an overall increase in resources of 8.4% in 2006/7 and 8.5% in 2007/8. This compares to a national average of 9.2% and 9.4% respectively.

'Based on the weighted capitation formula and pace of change policy, in 2006/07 allocations per head of population in England (un-weighted) will range from 982 to 1,824 with an average of 1,274. The allocations per head of population to PCTs in Surrey and Sussex range from 1002 to 1458 (e.g. Adur, Arun & Worthing 1389, Brighton & Hove City 1336, Horsham & Chanctonbury 1002 (lowest), Hastings & St Leonards 1458 (highest)).

Despite the undoubted integrity of the formula it is intuitively difficult to understand and explain why some parts of the country should receive nearly twice the level of funding per head of population than others.'(3)

'The implementation of Payment by Results and in particular the transitional arrangements related to this, effectively amounts to a further allocation process. This creates a double funding blow for Surrey and Sussex since on the one hand it receives only marginally more than the minimum level of growth due to its capitation position, whilst on the other

there is a net cost to the health economy arising from the Payment by Results (PbR) transition arrangements.' (3) These PbR transition arrangements can be summarized thus 'the benefits to Trusts with below average reference costs moving to the national tariff and the new market forces factor, is being capped in 2006/07 and 2007/08'. i.e we will not generate income by performing well in health economics terms. In 2008/09 when the cap is removed Trusts stand to gain significantly. As a consequence Surrey & Sussex will loose 40 million in EACH of the next 2 financial years. This will become a 40 million gain in 2008/09 when the cap is removed. Interestingly if our Acute Trusts had been treated in the same way as Foundation Trusts then the gain for EACH individual Trust would have been 59.7 million in 2006/07 and 17.4 million in 2007/08.

Resource Accounting & Budgeting (RAB) scheme applies to all government departments. 'It effectively means that financially challenged organisations have to both respond to their underlying recurrent deficit (ie to bring their monthly run rate back into balance) and repay the overspend from

the previous year.'

'The scale of RAB deficit which the Surrey and Sussex health economy has

had to contend with, in addition to addressing the underlying recurrent

deficit, is set out below:'

Summary: We are in the wrong place at the wrong time.

1. The weighted capitation formula is repeatedly challenged over the various elements of this formula and their weightings. There are currently calls for expressions of interest into NHS resource allocation research to review the need formula again! 'Despite the undoubted integrity of the formula it is intuitively difficult to understand and explain why some parts of the country should receive nearly twice the level of funding per head of population than others.'

2. The pace of change policy means that Surrey & Sussex PCTs will receive a below national average increase in resources for 2006/07 and 2007/08.

3. The PbR transitional arrangements will mean a loss of 40 million to Surrey & Sussex PCTs for the years 2006/07 and 2007/08. If our Acute Trusts had been treated in the same way as Foundation Trusts then the gain for EACH individual Trust would have been 59.7 million in 2006/07 and 17.4 million in 2007/08.

4. The Resource Accounting & Budgeting (RAB) scheme will result in 120 million underlying 'in-year' deficit.

A 'manufactured' deficit created as a consequence of central government belief that the South of England is an over-resourced Health Economy is not a justification for the proposed SHA changes in 'Settings of Care'. Those of us involved in delivering Health Care recognize that we are currently under-resourced, and any quality improvements in Health Care are welcomed but will also have significant cost implications.

Volume of care and quality of care at WASH '“ Is WASH fit for the future?

'Settings of care' discusses the benefits of 'high' versus 'low' volume surgery, and uses this as a reason for the centralisation of acute services in very large hospitals. The scanty evidence to support this hypothesis is based around cardiac, oesophageal and aortic surgery. Other studies have shown that networks can avert this problem, and this is currently the direction in which Worthing Hospital has moved '“ networks have been created for aortic (Brighton) and oesophageal (Guildford) surgery, whereas cardiac surgery is not applicable for Worthing Hospital. However nationwide aortic and oesophageal surgery is low volume surgery, and 'Settings of care' completely ignores the huge amount of other elective and emergency major surgery that occurs in Worthing Hospital. The figures below speak for themselves, and when the elective surgery and acute medicine numbers are looked out as well, it is inconceivable that any hospital in the South of England could cope with this massive work load if Worthing Hospital were to close.

All data relates to 12 month period October 2005 - September 2006 except where stated.

source: SEMA Helix PAS

Table 1. Emergency admissions

Specialty group Number of admissions

Medicine 7,462

Cardiology 969

DOME 3,672

General Surgery 3,812

Urology 168

Orthopaedics 1,945

O&G1 890

General maternity admissions 7,365

Paediatrics 2,705

Critical Care Unit 679

Other specialties 673

TOTAL 22,296

1 Excluding general maternity admissions.

Table 2. Emergency operations

Specialty group Number of episodes

Surgery 1,344

Orthopaedics 1,286

O&G 428

Paediatrics 152

Laparotomies 198

#NOF 427

Table 3. A&E attendances (2005/06 financial year)

Total attendances 62,879

Admissions via A&E 14,150

Table 4 New consultant outpatient episodes1

Specialty group Number of new consultant episodes

Medicine 4944

Cardiology 2488

DOME 1178

Surgery 7319

Urology 3426

ENT 5673

Orthopaedics 13271

O&G 5514

Paediatrics 1828

Ophthalmology2 9431

Dermatology 3722

Other specialties 10337

TOTAL 69131

1 1st consultant outpatient attendance used as proxy for new episodes of care. Therefore excludes nurse only episodes.

2 Excludes St Richards ophthalmology (approx 4400 p.a.)

Table 5 Other information requested (elective surgery)

Number of admissions

Elective joint replacements 709

Complex/major abdominal/intestinal procedures 649

TURP 133

Breast reconstructions/mastectomies 286

Other major/intermediate breast surgery 93

3. Your health, your care, your say '“ What did the 'people' really say?

Reference: Your health, your care, your say. Research report, January 2006,

Prepared for department of health by opinion leader research

'¢ Background: In July 2005, Opinion Leader Research was commissioned to conduct the research components of the Department of Health's Your Heath, Your Care, Your Say listening exercise, which informed the development of the White Paper on Care Outside Hospitals. This report is based on the views of at least 42,866 people in total:

o 29,808 people who completed the self-completion online and paper-based core questionnaire

o The questions were adapted for use in magazines; 3,358 people completed them

o 8,460 people who took part in local listening exercises;

o 254 people randomly selected from a number of electoral registers in the region who took part in deliberative regional events during September and October 2005 (89 in Gateshead, 60 in Leicester, 51 in London, 54 in Plymouth)

o 986 people randomly selected from electoral registers around the country who took part in a 'National Citizens' Summit' in Birmingham on 29 October 2005; this focused in on specific issues that emerged from earlier deliberative events and the core questionnaire response

'¢ Results: When asked, many people are interested in new and innovative ways of providing hospital services in community settings (including diagnostic tests, routine surgery, etc) They think getting services locally would be more accessible (e.g. reducing wait times for appointments and treatment; reducing journey times to appointments; making it easier for family and friends to visit in-patients, etc) and they think community services would also offer better customer service and improved communication. However, many fear this would mean closure of local hospitals

o Summary of main findings

People do not spontaneously call for hospital services to be provided locally. They do not expect to see such changes. However, when asked, they can see benefits in doing so.

A substantial proportion oppose the suggestion. They think the Government is proposing to close hospitals via the 'back door'.

?Before they are willing to endorse this option, they want reassurances that:

- Their emergency care needs will continue to be met effectively (ensuring rapid access to A&E is a widespread concern)

- Community-based services will be appropriately staffed

- Waiting times both for and at appointments will be reduced

- Delivering hospital services in community settings will be more cost effective, and less bureaucratic

- Quality of services in community settings will be effectively regulated

- The accessibility and quality of services that are still provided in hospitals will be improved

Participants did suggest that a wide range of services could be conducted in the community rather than in hospitals, specifically, they mention:

Diagnostic tests, e.g. blood tests, X rays, etc.

Minor surgery for removal of cysts, warts, moles etc

Physiotherapy

Chiropody

NOT ACUTE CARE

'¢ Disadvantages Of Moving Services Into The Community

The main concerns about moving services into the community centre around two issues:

The impact on hospitals (resistance to closures of local hospitals and concern about increased travel time)

Issues with delivering services locally (including speed of treatment, staffing, quality and cost)

Participants at the Citizens' Summit were asked to discuss whether they would like to see more services provided locally if this meant that some local hospitals would close and others would merge to become specialist centres.

There is substantial resistance to the idea of local hospitals being closed and people trust hospitals to provide high quality treatment and services

They are not sure whether local services will be able to provide the same high quality

People feel that governments in the past had been to quick to close local and community hospitals, which had been a mistake and some also think that there is likely to be more need for hospital services in the future not less, because the population is ageing and more people are living with long term conditions

People are concerned that traveling time to specialist hospitals would be longer. This is a particular concern in some situations:

Emergencies

Situations where people are feeling very unwell

Regular treatments which could involve daily visits such as radio or chemo therapy

It is also an issue for visiting patients in hospital.

Participants are divided on this issue:

Some accept that longer journeys would be necessary for specialist treatment, as this was unlikely to happen regularly

Others are not prepared to travel further when they are ill

Some say that the issue could be addressed by providing better and cheaper public transport to services

Participants at the Citizens' Summit were prompted to discuss whether they would be prepared to wait longer to receive services locally, e.g. waiting times might be longer if a specialist only conducts a clinic in each area once a month. Very few participants are willing to wait longer for treatment in the community

As discussed above, the initial assumption is that treatment in the community should be quicker. Unless it is a minor problem, most people would not be willing to wait and would rather travel to a hospital for an appointment. Even those who say they might be willing to wait for local treatment because it would be more convenient also say there are limits to their willingness to wait depending on exactly how much longer it would be

Staffing is seen as one of the main challenges for the new system for a range of reasons: People believe that the country has problems with shortages of nurses and doctors

They think the new system may be more convenient for patients but will involve more traveling time for doctors. Local centres are likely to need more nurses and other support staff to deliver additional services

Many participants are concerned about the quality of service they would receive locally: People question how standards would be monitored if more services are delivered locally. They think it is difficult to monitor standards even in a centralised hospital, and that it would be even more difficult in a more decentralised system. There are also concerns that it might result in an increase in bureaucracy and linked to the point above about staffing, people are concerned that the staff in local centres might have less expertise than staff in hospitals

People also think that local centres would have less sophisticated equipment than hospitals

Some feel that they would be unlikely to be able to see the best specialists in local community services

People are also concerned that the costs of providing services locally would be very high: They anticipate that it would involve new buildings or duplication of specialist equipment such as scanning or X ray equipment

They think that more administration and bureaucracy would be generated by having to co-ordinate a large number of local centres rather than one centralised hospital.

4. Making the shift to Community Care - Does it work, and is it cheaper?

Reference: Making the shift: key Success Factors. A rapid review of best practice in shifting hospital care into the community. University of Birmingham, NHS institute for Innovation & Improvement. July 2006

Rationale for this review: 'The aim is to reduce reliance on hospital care, with greater emphasis on community-based specialists and services, including nurses, GPs with special interests, and community based diagnostic and treatment facilities. The challenge is to make best practice in the NHS the norm, rather than the exception. Shifting care has to be evidence-based.' Department of Health. Our health, Our Care, Our say: a new direction for community. London: The stationary Office,2006:131.

'¢ Key summary points from review:

o 'Shifting the focus from hospital to primary care requires much more than simply moving services out of hospital. In fact, there is little evidence that moving hospital specialists or equipment into community venues will help reduce reliance upon secondary care.'

o 'It cannot be assumed that shifting care from hospital will automatically reduce costs.'

o 'Services are often introduced without thorough analysis of the level and types of activity needed to improve access, the human resources needed to deliver it, or the costs this should entail.' Audit Commission. Quicker treatment closer to home. London, 2004.

o 'In many instances the quality and scope of the evidence is lacking'

o 'Much of available evidence is sourced from the United States or Europe, which have very different health care economies and styles of working to the UK'. Studies which compare an intervention with 'usual care' in Europe / USA may be very different from 'usual care' in the UK.

'¢ Details of review:

a) Managed Care Programs focus on patients with chronic heart failure and can reduce hospital or nursing home length of stay, and avoid need for hospital admission. Key factors for success are:

o Joint working by cardiologists and nurses

o Patient education

o Lifestyle changes

o Exercise

o Home visits

o Nurse case managers

o Multidisciplinary team

o Weekly mailings and telephone calls

o Home monitoring

o Intensive outpatient support in primary care

We believe that this is a commendable improvement in quality of care, and a similar program has recently been attempted by the cardiologists at WASH, until funding was withdrawn from the PCT. These programs are of course expensive to create and maintain, and are in addition to best hospital cardiology care (e.g. insertion of pacemaker, automatic defibrillator). Reduced costs shown in some USA studies used expensive American hospital practices as 'normal care', which bear no comparison to practice at WASH. Finally it is difficult to isolate which components of these many interventions may be most beneficial, or which best supports shifts in models of care.

Specific components of managed care programmes:

o Shared care can improve satisfaction, but no evidence that reduces reliance on hospital services or prevents readmission to hospital, and are unlikely to e cost effective.

o Multidisciplinary teams: Adding specialists to primary care teams have no effect on hospital referral rates, health outcomes, or GP workload. Indeed pharmacist medication reviews were associated with a significantly higher rate of unscheduled admissions which has implications for the creation of GP specialists who may prescribe and/or investigate more and unnecessarily. Unscheduled admissions are likely to increase because patients will want to see 'the Consultant'. However Integrated Hospital Teams may make the shift from hospital to community care, and WASH is actively pursuing this concept.

b) Changing location.

o Hospital at home: May be as effective as traditional hospital care so long as participants are carefully selected. Reduced hospital stay costs were offset by costs incurred in the community, and although there was some evidence that service users preferred care at home, carers' views were mixed.

o Home visits to reduce admissions: This service is an 'add on' to other services rather than substituting for care in another location, and therefore costs will not be reduced. Unfortunately not all the evidence supports the premise that home visits will reduce readmissions, LOS, emergency department visits.

o Intermediate care (' community hospital beds'): provides an additional service rather than substituting for hospital services and there is no evidence that this will 'make the shift'.

o Outpatient clinics in primary care, community venues: While services may be more accessible and convenient for patients and may improve the perceived quality of care, it is unlikely to be cost-effective. In fact this may reduce the number of patients seen and increase overall health service costs.

c) By substitution

o GP with special interests: Their cost effectiveness has been questioned, and they do not improve health outcomes. Referral rates from GPs increase, and they are considered an addition to hospital outpatient care rather than as a substitute.

o GPs performing minor surgery: There are concerns over the quality of care provided, and many patients receiving minor surgery in general practice would not be referred to hospital. This service is an addition rather than a substitute to hospital care.

d) Changing hospital care

o Rapid access clinics: Effective and current practice at WASH

o Observation units: Reduce unnecessary hospital admissions, decrease length of stay, and create cost savings. Consultant body at WASH have already recommended creation of an observation unit, but again funding is not available.

o Day surgery: Effective and current practice at WASH

o Discharge planning: Effective and current practice at WASH

e) Technology Insufficient evidence to support telemedicine, telecare at present, although Consultant body at WASH are very enthusiastic to trial this technology. Again funding would be an issue.

f) Supporting self care (written information, clinical education sessions, self management education, self monitoring, written plans, patient-held records, open access to OPD care). No evidence at present, and uncertain effects.

g) Substituting organisations (treatment centres, community groups). No evidence at present and uncertain effects.

h) Targetting people (registries, risk assessment tools, changing referral behaviours). No evidence at present and may not target those most in need of referral.

i) Simplifying pathways

o Formal care pathways (eg NSF) may help develop high quality service but little evidence that will help shift care from hospital into community

o Direct access to diagnostics. Probably worth pursuing, although only likely to be effective for tests that GPs know a lot about. Current practice at WASH.

o Direct referral to treatment by GP. Limited evidence of good health outcomes and savings offset by increased referrals.

'¢ Summary: Effective quality practices recommended by KWASH

Managed Care Programs Funding withdrawn following attempted implementation at WASH

Integrated Hospital Teams Current practice at WASH

Rapid Access Clinics Current practice at WASH

Observation Unit Recommended by Consultant body WASH, but no funding.

Day Surgery Current practice at WASH

Telemedicine Recommended by Consultant body WASH, but no funding.

Direct GP access to diagnostics Current practice at WASH

'¢ 'Merely relocating secondary services or specialists into primary care settings will not reduce demand on hospital resources.'

'¢ 'Do not assume that shifts will reduce costs'

5. Impact of EWTD '“ Can WASH sustain a service?

The European Working Time Directive (EWTD) dictates a current 56-hour working week, and a reduction to 48 hours by 2009. Currently WASH is fully compliant with this directive. The majority of doctors in the UK do not support the working hours reduction to 2009 European targets and interestingly many countries in Europe already pay 'lip-service' to the present EWTD, when applied to medical staff. The major concern by both Consultants and Consultant trainees relates to training issues. WASH is working hard to ensure that we are 2009 EWTD compliant as well as addressing these training issues. Some emergency specialties are already 2009 EWTD compliant and the remaining emergency specialities are already within a few hours of being compliant. The local population can be reassured that any concerns expressed by the SHA in 'Creating an NHS fit for the future' regarding staffing levels at WASH as a consequence of the EWTD, are unfounded.

6. Who will decide the fate of the sick patient if acute services are removed from WASH? Can the primary care physician, community matron or paramedic triage emergency calls and decide which patient requires an acute medical and surgical hospital admission?

'Settings of Care' claims that the work performed at WASH (see section 2) can be absorbed in the community by urgent care centres, community hospitals and when required 'the very large hospital'. The Royal Sussex County Hospital, Brighton has already acknowledged that it does not have the capacity to cope with the elective and emergency workload at WASH, and at present WASH frequently helps Brighton out with their emergency workload when they are over-capacity.

The emergency inpatient workload at WASH will not disappear if the SHA removes acute services at WASH, and this workload requires access to an intensive care facility (level 2 or 3 care). Transfers of critically ill patients from a Worthing community hospital environment to an intensive care facility at this imaginary 'very large hospital' will cost lives. Adverse events occured in 34% of interhospital transfers, and 37% of patients deteriorated during transfer in a Dutch study addressing this problema. 6% of these transferred patients died within 24 hours of arrival at the receiving hospitala.

Furthermore a descriptive study by Kathy Rowan of 46,587 intensive care admissions in England, Wales and Northern Ireland confirms that this delay will dramatically increase mortalityb. Admissions to ICU from the emergency department had a hospital mortality of 31% when admitted directly from the emergency department versus 44% in those patients whose ICU admission was delayed by transfer to a hospital ward prior to ICU. Finally a large French study of 3,416 patients admitted to a tertiary referral ICU showed that patients transferred from the ward of another hospital had significantly higher mortality rates (odds ratio=1.56) as compared with patients directly admitted from the ward of the same hospitalc. Even if the public were to accept this high level of risk, the costs of equipping and staffing an emergency medical retrieval service, for the large numbers of WASH patients that this would involve (see section 2), would negate any savings due to the advanced medical intervention required to ensure 'safe' transferd.

Claims by 'Settings of Care' that the emergency inpatient workload of WASH could be triaged prior to community hospital admission, even if there was capacity in 'the very large hospital' elsewhere, are not supported by the evidence. Telephone assessment for the ambulance service by paramedics or nurses of non-serious problems (Category C calls) resulted in a significant proportion (10%) of patients triaged as not requiring immediate despatch of an emergency ambulance, being subsequently admitted to inpatient hospital care, raising concerns about the safety of the interventione. Further examination of this group showed disagreement by the expert opinion (Emergency Department Consultants and nurses, GPs and paramedics) about the need for attendancef! The authors of this study conclude ' It is now national policy that NHS Direct, the national nurse led telephone advice service, will in future triage emergency calls that are prioritised as being of a non-urgent nature. We consider that widespread adoption will be premature without further safety evaluation.' Interestingly this paper is been used by the DoH to promote nurse/paramedic telephone triage (Taking Healthcare to the Patient: Transforming NHS Ambulance Services; June 2005), and yet again one wonders whether anyone in the DoH bothers to read these peer-reviewed studies.

The ability of the clinician to recognise the sick patient or predict the need for ICU by assessing severity and perceived progression of the patient' physiology, is very difficult. Decision-making protocols do not exist. Over 50% of current ICU admissions at WASH arrive from the wards and not directly from the emergency department. These patients have often already been triaged by their GP, the A&E doctor, and a surgical or medical registrar, and still the triage decision has failed to identify the sick patient. Furthermore attempts by senior hospital consultants to triage GP admission requests to Southlands Hospital ('community hospital') or Worthing Hospital ('acute hospital with critical care facilities') has effectively been abandoned. Too often the sick patient requiring the acute hospital was not identified by telephone triage, resulting in a further rapid ambulance transfer of an already sick patient from the community to acute hospital.

Summary:

1) 'Settings of care' ignores the obvious question of where the huge current in-patient work-load of WASH will be re-housed, if acute services are withdrawn from Worthing Hospital.

2) Interhospital transfer of sick patients kills patients and will be very expensive.

3) Identification of those patients, prior to hospital admission, who will require in-patient hospital care and those who may require intensive care facilities, is difficult even for hospital specialists.

4) There are safety concerns for telephone triage by nurses / paramedics for non-serious problems, and calls for further safety evaluations have been advised.

a - Critical Care 2005,9;446-451

b - Emerg Med J 2005;22:423-428

c - Crit Care Med 2005;33:705-10

d - Emerg Med J 2006;23:679-83

e - Emerg Med J 2003;20:178-183

f - Qual Saf Health Care 2004;13:363-73